MEDICARE: DR. THELMA TAN DMD

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	19670	TX

General Provider Information

NPI Number	:	1942317581
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THELMA TAN DMD

Provider Business Mailing Address
First Line	:	15 WALLER ST
Second Line	:	ATTN: FINANCE, 5TH FLOOR
City	:	AUSTIN
State	:	TX
Zip	:	78702-5240
Country	:	US
Telephone Number	:	512-978-9000
Fax Number	:	512-978-9001

Provider Business Practice Location Address
First Line	:	2529 S 1ST ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78704-5466
Country	:	US
Telephone Number	:	512-978-9865
Fax Number	:

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

Provider Enumeration Date	:	08/23/2006
Last Update Date	:	01/30/2012

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