=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255505533
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROSITA D TAN DMD INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2008
-----------------------------------------------------
Last Update Date | 09/22/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4560 ADMIRALTY WAY SUITE 350
-----------------------------------------------------
City | MARINA DEL REY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90292-5423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-822-8481
-----------------------------------------------------
Fax | 310-822-8083
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4560 ADMIRALTY WAY SUITE 350
-----------------------------------------------------
City | MARINA DEL REY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90292
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-822-8481
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ROSITA D TAN
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 310-822-8481
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 40027
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------