Provider Demographics
NPI:1003162934
Name:TAN, JEFF S (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFF
Middle Name:S
Last Name:TAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 E VISTA RIDGE MALL DR
Mailing Address - Street 2:APT #331
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-3716
Mailing Address - Country:US
Mailing Address - Phone:213-255-1485
Mailing Address - Fax:
Practice Address - Street 1:930 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-3516
Practice Address - Country:US
Practice Address - Phone:469-444-1595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-30
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX282401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice