Provider Demographics
NPI:1932585916
Name:TAN, PETER M JR (DDS)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:M
Last Name:TAN
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1553 HUGO CIR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20906-5918
Mailing Address - Country:US
Mailing Address - Phone:301-639-2536
Mailing Address - Fax:
Practice Address - Street 1:2480 LLEWELLYN AVE
Practice Address - Street 2:
Practice Address - City:FORT GEORGE G MEADE
Practice Address - State:MD
Practice Address - Zip Code:20755-7081
Practice Address - Country:US
Practice Address - Phone:301-677-8956
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-03
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD15999122300000X
WV43671223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No122300000XDental ProvidersDentist