Provider Demographics
NPI:1386782985
Name:TRAN, TAM K
Entity type:Individual
Prefix:DR
First Name:TAM
Middle Name:K
Last Name:TRAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 E HAZELTINE ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-8723
Mailing Address - Country:US
Mailing Address - Phone:909-381-6507
Mailing Address - Fax:714-571-3560
Practice Address - Street 1:1199 N E ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-3507
Practice Address - Country:US
Practice Address - Phone:909-381-6507
Practice Address - Fax:909-381-9517
Is Sole Proprietor?:No
Enumeration Date:2007-02-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48559122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD48559Medicaid