Provider Demographics
NPI:1568668044
Name:TOM, VIVIAN (DDS)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:TOM
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 1:1818 W BURBANK BLVD
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91506-1348
Mailing Address - Country:US
Mailing Address - Phone:818-845-1377
Mailing Address - Fax:818-845-4288
Practice Address - Street 1:1818 W BURBANK BLVD
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91506-1348
Practice Address - Country:US
Practice Address - Phone:818-845-1377
Practice Address - Fax:818-845-4288
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39357122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist