Active NPI
Ellis Chan Back, DDS
- Dentist
- Vallejo, CA
National Provider Identifier
1841064094
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 109664
- Practice address
- 3587 Sonoma Blvd
Vallejo, CA 94590-2945 - Phone
- (925) 683-4799
- NPI assigned
- Nov 8, 2023
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 109664 | CA | Primary |
Addresses
Primary practice location
3587 Sonoma Blvd
Vallejo, CA 94590-2945
Mailing address
962 El Cajon Dr
Danville, CA 94526-1935
Phone (925) 683-4799
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 109664 | CA | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1699401600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1699401600000",
"number": "1841064094",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "962 EL CAJON DR",
"city": "DANVILLE",
"state": "CA",
"postal_code": "945261935",
"telephone_number": "925-683-4799"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "3587 SONOMA BLVD",
"city": "VALLEJO",
"state": "CA",
"postal_code": "945902945",
"telephone_number": "925-683-4799"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BACK",
"first_name": "ELLIS",
"middle_name": "CHAN",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2023-11-08",
"last_updated": "2023-11-08",
"certification_date": "2023-11-08",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "CA",
"license": "109664",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Vallejo, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 8, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.