=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700976461
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARILOU C. TAN, D.D.S. PROFESSIONAL DENTAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7850 STOCKTON BLVD SUITE #160
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95823-4319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-689-3310
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7850 STOCKTON BLVD SUITE #160
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95823-4319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-689-3310
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARILOU C. TAN
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 916-689-3310
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------