Provider Demographics
NPI:1427040252
Name:ANTONIO, MARY YVETTE TAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARY YVETTE
Middle Name:TAN
Last Name:ANTONIO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:YVETTE
Other - Middle Name:TAN
Other - Last Name:ANTONIO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:327C MOFFETT BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94043-4725
Mailing Address - Country:US
Mailing Address - Phone:650-961-5424
Mailing Address - Fax:650-961-5466
Practice Address - Street 1:327 MOFFETT BLVD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94043-4757
Practice Address - Country:US
Practice Address - Phone:650-961-5424
Practice Address - Fax:650-961-5466
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA490531223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice