Provider Demographics
NPI:1376079640
Name:TIAN, YUAN
Entity Type:Individual
Prefix:
First Name:YUAN
Middle Name:
Last Name:TIAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13630 MAPLE AVE STE 1H
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11355-3869
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13630 MAPLE AVE STE 1H
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-3869
Practice Address - Country:US
Practice Address - Phone:718-799-0779
Practice Address - Fax:718-799-0778
Is Sole Proprietor?:No
Enumeration Date:2017-05-05
Last Update Date:2023-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS041929122300000X
NY0600951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice