MEDICARE: CHRISTALLYN TAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	57398	CA

General Provider Information

NPI Number	:	1215188586
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHRISTALLYN TAN

Provider Business Mailing Address
First Line	:	1860 ALCATRAZ AVE
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94703-2715
Country	:	US
Telephone Number	:	510-653-8500
Fax Number	:

Provider Business Practice Location Address
First Line	:	1860 ALCATRAZ AVE
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94703-2715
Country	:	US
Telephone Number	:	510-653-8500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2008
Last Update Date	:	10/06/2008

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Directions to “ CHRISTALLYN TAN ” Practice Location

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