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NPI Code Detail

MEDICARE: KEVIN TAN DDS LLC

MEDICARE: KEVIN TAN DDS LLC
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
11223G0001XGeneral Practice Dentistry

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
17778OTHERNVDENTAL LICENSE

General Provider Information

NPI Number : 1962389106
Entity Type Code : Organization
Provider Name (Legal Business Name) : KEVIN TAN DDS LLC
Provider Business Mailing Address
First Line : 4205 S GRAND CANYON DR STE 19
Second Line :
City : LAS VEGAS
State : NV
Zip : 89147-7152
Country : US
Telephone Number : 702-805-1117
Fax Number :
Provider Business Practice Location Address
First Line : 4205 S GRAND CANYON DR STE 19
Second Line :
City : LAS VEGAS
State : NV
Zip : 89147-7152
Country : US
Telephone Number : 702-805-1117
Fax Number : 702-805-1180
Authorized Official
Title or Position : OWNER DENTIST
Name : DR. KEVIN TAN
Credential : DDS
Telephone Number : 702-805-1117
Provider Enumeration Date : 08/19/2025
Last Update Date : 08/19/2025

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