Healthcare Provider Details

I. General information

NPI: 1104080928
Provider Name (Legal Business Name): KRISTIAN TJON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 10/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 N TUSTIN AVE SUITE 345
SANTA ANA CA
92705-8644
US

IV. Provider business mailing address

1401 N TUSTIN AVE SUITE 345
SANTA ANA CA
92705-8644
US

V. Phone/Fax

Practice location:
  • Phone: 714-835-1015
  • Fax: 714-835-3779
Mailing address:
  • Phone: 714-835-1015
  • Fax: 714-835-3779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number56872
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: