MEDICARE: DR. MARY YVETTE TAN ANTONIO DDS

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	1223G0001X	General Practice Dentistry	49053	CA

General Provider Information

NPI Number	:	1427040252
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY YVETTE TAN ANTONIO DDS

Provider Business Mailing Address
First Line	:	327C MOFFETT BLVD
Second Line	:
City	:	MOUNTAIN VIEW
State	:	CA
Zip	:	94043-4725
Country	:	US
Telephone Number	:	650-961-5424
Fax Number	:	650-961-5466

Provider Business Practice Location Address
First Line	:	327 MOFFETT BLVD
Second Line	:
City	:	MOUNTAIN VIEW
State	:	CA
Zip	:	94043-4757
Country	:	US
Telephone Number	:	650-961-5424
Fax Number	:	650-961-5466

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

Provider Enumeration Date	:	08/18/2005
Last Update Date	:	07/08/2007

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