MEDICARE: MICHAEL TUAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	122300000X	Dentist	30-024260	OH
3	122300000X	Dentist	65040	CA

General Provider Information

NPI Number	:	1184964710
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL TUAN

Provider Business Mailing Address
First Line	:	2041 BRONZE STAR DR
Second Line	:	SUITE 300
City	:	WOODLAND
State	:	CA
Zip	:	95776-5427
Country	:	US
Telephone Number	:	510-847-5099
Fax Number	:

Provider Business Practice Location Address
First Line	:	2041 BRONZE STAR DR
Second Line	:	SUITE 300
City	:	WOODLAND
State	:	CA
Zip	:	95776-5427
Country	:	US
Telephone Number	:	510-847-5099
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/19/2013
Last Update Date	:	08/28/2015

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