Healthcare Provider Details

I. General information

NPI: 1831451004
Provider Name (Legal Business Name): ROSITA D. TAN DMD, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2012
Last Update Date: 06/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4560 ADMIRALTY WAY SUITE 350
MARINA DEL REY CA
90292-5423
US

IV. Provider business mailing address

4560 ADMIRALTY WAY SUITE 350
MARINA DEL REY CA
90292-5423
US

V. Phone/Fax

Practice location:
  • Phone: 310-822-8481
  • Fax: 310-822-8083
Mailing address:
  • Phone: 310-822-8481
  • Fax: 310-822-8083

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number40027
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. ROSITA D TAN
Title or Position: OWNER
Credential: DMD
Phone: 310-822-8481