MEDICARE: DR. KIMTY TAN D.M.D

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	122300000X	Dentist	DS026581-L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265424642
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KIMTY TAN D.M.D

Provider Business Mailing Address
First Line	:	5761 N 6TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19120-2201
Country	:	US
Telephone Number	:	215-924-8056
Fax Number	:

Provider Business Practice Location Address
First Line	:	1018 W LEHIGH AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19133-1640
Country	:	US
Telephone Number	:	215-227-1881
Fax Number	:

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

Provider Enumeration Date	:	08/22/2005
Last Update Date	:	07/08/2007

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