Provider Demographics
NPI:1285835884
Name:PHAN, PETER TAN (DMD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:TAN
Last Name:PHAN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 PINEGROVE RD
Mailing Address - Street 2:
Mailing Address - City:HINGHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02043-3923
Mailing Address - Country:US
Mailing Address - Phone:617-785-0759
Mailing Address - Fax:
Practice Address - Street 1:8 SPRING LN
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-3437
Practice Address - Country:US
Practice Address - Phone:508-591-5951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN218421223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics