Provider Demographics
NPI:1043426976
Name:VERANUNT, REVADEE TAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:REVADEE
Middle Name:TAN
Last Name:VERANUNT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5065 HOLLYWOOD BLVD
Mailing Address - Street 2:#205
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6133
Mailing Address - Country:US
Mailing Address - Phone:323-666-9881
Mailing Address - Fax:323-666-9881
Practice Address - Street 1:5065 HOLLYWOOD BLVD
Practice Address - Street 2:#205
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6133
Practice Address - Country:US
Practice Address - Phone:323-666-9881
Practice Address - Fax:323-666-9881
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36120122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist