Basic Information
| Provider Information | |||||||||
| NPI: | 1841336898 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHEN | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2144 S BRISTOL ST | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927045123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7147845779 | ||||||||
| FaxNumber: | 3232497565 | ||||||||
| Practice Location | |||||||||
| Address1: | 2144 S BRISTOL ST | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927045123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7147845779 | ||||||||
| FaxNumber: | 3232497565 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 12/12/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 47460 | CA | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | D47460 | 05 | CA | MEDICAID |