Provider Demographics
NPI:1699544296
Name:TAN, EDWARD GAO (DMD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:GAO
Last Name:TAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1055 SUMMIT DR
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651-3430
Mailing Address - Country:US
Mailing Address - Phone:760-828-8850
Mailing Address - Fax:
Practice Address - Street 1:1055 SUMMIT DR
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-3430
Practice Address - Country:US
Practice Address - Phone:760-828-8850
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-22
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109707122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist