MEDICARE: DR. DEBRA TAN D.D.S

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	63753	CA

General Provider Information

NPI Number	:	1730597071
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEBRA TAN D.D.S

Provider Business Mailing Address
First Line	:	2001 SANTA ANITA AVE
Second Line	:	SUITE 204
City	:	SOUTH EL MONTE
State	:	CA
Zip	:	91733-3442
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2001 SANTA ANITA AVE
Second Line	:	SUITE 204
City	:	SOUTH EL MONTE
State	:	CA
Zip	:	91733-3442
Country	:	US
Telephone Number	:	626-443-3915
Fax Number	:

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

Provider Enumeration Date	:	07/30/2014
Last Update Date	:	07/30/2014

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