Provider Demographics
NPI:1831451004
Name:ROSITA D. TAN DMD, INC
Entity type:Organization
Organization Name:ROSITA D. TAN DMD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSITA
Authorized Official - Middle Name:D
Authorized Official - Last Name:TAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:310-822-8481
Mailing Address - Street 1:4560 ADMIRALTY WAY
Mailing Address - Street 2:SUITE 350
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-5423
Mailing Address - Country:US
Mailing Address - Phone:310-822-8481
Mailing Address - Fax:310-822-8083
Practice Address - Street 1:4560 ADMIRALTY WAY
Practice Address - Street 2:SUITE 350
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-5423
Practice Address - Country:US
Practice Address - Phone:310-822-8481
Practice Address - Fax:310-822-8083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
332BC3200X
CA40027122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty