MEDICARE: DR. EDWIN M. TJAN DDS

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	1223G0001X	General Practice Dentistry	37295	CA

General Provider Information

NPI Number	:	1396903639
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDWIN M. TJAN DDS

Provider Business Mailing Address
First Line	:	20353 LAKE CHABOT RD
Second Line	:	#104
City	:	CASTRO VALLEY
State	:	CA
Zip	:	94546-5392
Country	:	US
Telephone Number	:	510-886-1113
Fax Number	:

Provider Business Practice Location Address
First Line	:	20353 LAKE CHABOT RD
Second Line	:	#104
City	:	CASTRO VALLEY
State	:	CA
Zip	:	94546-5392
Country	:	US
Telephone Number	:	510-886-1113
Fax Number	:

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

Provider Enumeration Date	:	05/22/2008
Last Update Date	:	05/22/2008

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