Provider Demographics
NPI:1124280664
Name:TAN DENTAL PRACTICE PLLC
Entity type:Organization
Organization Name:TAN DENTAL PRACTICE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:STELLA
Authorized Official - Middle Name:EI BE
Authorized Official - Last Name:TAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:917-515-8226
Mailing Address - Street 1:6854 CLYDE ST
Mailing Address - Street 2:APT 2
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-5038
Mailing Address - Country:US
Mailing Address - Phone:718-268-2798
Mailing Address - Fax:
Practice Address - Street 1:6854 CLYDE ST
Practice Address - Street 2:APT 2
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-5038
Practice Address - Country:US
Practice Address - Phone:718-268-2798
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY04986411223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty