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General NPI Number Information
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NPI Number | 1629777552
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Entity Type | Individual
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Provider Name | MIN-U TAN
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Gender | Male
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Dates
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Enumeration Date | 02/28/2023
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Last Update Date | 02/28/2023
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Provider Practice Location Address
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Address Line | 4855 SW WESTERN AVE
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City | BEAVERTON
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State | OR
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Zip | 97005-3499
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Country | US
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Telephone | 503-813-2000
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Fax |
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Provider Business Mailing Address
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Address Line | 14820 NE 74TH CIR
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City | VANCOUVER
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State | WA
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Zip | 98682-5097
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Country | US
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Telephone | 360-281-5388
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Fax |
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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 | 122400000X
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Taxonomy Name | Denturist
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License Number | DN61216096
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 126900000X
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Taxonomy Name | Dental Laboratory Technician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 122400000X
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Taxonomy Name | Denturist
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License Number | DT-DO-10222225
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License Number State | OR
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