Healthcare Provider Details

I. General information

NPI: 1891332789
Provider Name (Legal Business Name): TATH FAMILY DENTAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2019
Last Update Date: 12/11/2019
Certification Date: 12/11/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 TOWNE CENTRE DR
LATHROP CA
95330-9533
US

IV. Provider business mailing address

220 TOWNE CENTRE DR
LATHROP CA
95330
US

V. Phone/Fax

Practice location:
  • Phone: 209-597-3145
  • Fax:
Mailing address:
  • Phone: 209-597-3145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: PON TATH
Title or Position: PRESIDENT
Credential: DMD
Phone: 209-597-3145