MEDICARE: KEVIN TOM 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	DV34236	CA

General Provider Information

NPI Number	:	1700910148
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN TOM DDS

Provider Business Mailing Address
First Line	:	359 EL CAMINO REAL
Second Line	:
City	:	SOUTH SAN FRANCISCO
State	:	CA
Zip	:	94080-5923
Country	:	US
Telephone Number	:	650-873-3732
Fax Number	:	650-588-4746

Provider Business Practice Location Address
First Line	:	359 EL CAMINO REAL
Second Line	:
City	:	SOUTH SAN FRANCISCO
State	:	CA
Zip	:	94080-5923
Country	:	US
Telephone Number	:	650-873-3732
Fax Number	:	650-588-4746

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

Provider Enumeration Date	:	03/16/2007
Last Update Date	:	03/19/2014

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