Provider Demographics
NPI:1316057094
Name:CHAN, BOSCO PUI-KI (DDS)
Entity type:Individual
Prefix:DR
First Name:BOSCO
Middle Name:PUI-KI
Last Name:CHAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 W CHICAGO ST
Mailing Address - Street 2:
Mailing Address - City:COLDWATER
Mailing Address - State:MI
Mailing Address - Zip Code:49036-2805
Mailing Address - Country:US
Mailing Address - Phone:517-278-6077
Mailing Address - Fax:517-278-7045
Practice Address - Street 1:323 W CHICAGO ST
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-2805
Practice Address - Country:US
Practice Address - Phone:517-278-6077
Practice Address - Fax:517-278-7045
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010100551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2901010055OtherCONTROLLED SUBSTANCE LIC
MI2901010055OtherDENTIST LICENSE STATE MI
MI2901010055OtherDENTIST LICENSE STATE MI