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General NPI Number Information
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NPI Number | 1164569646
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Entity Type | Individual
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Provider Name | MARISTELA TAN D.M.D.
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Gender | Female
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Dates
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Enumeration Date | 01/31/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 2440 N TEXAS ST
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City | FAIRFIELD
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State | CA
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Zip | 94533-1602
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Country | US
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Telephone | 707-422-4600
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Fax | 707-422-0396
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Provider Business Mailing Address
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Address Line | 2440 N TEXAS ST
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City | FAIRFIELD
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State | CA
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Zip | 94533-1602
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Country | US
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Telephone | 707-422-4600
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Fax | 707-422-0396
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 50829
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License Number State | CA
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