Provider Demographics
NPI:1629829452
Name:TAN, DEXTER
Entity Type:Individual
Prefix:
First Name:DEXTER
Middle Name:
Last Name:TAN
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 1:2500 ALLUVIAL AVE
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-9544
Mailing Address - Country:US
Mailing Address - Phone:559-701-2102
Mailing Address - Fax:
Practice Address - Street 1:1400 FLORIDA AVE STE 102
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4446
Practice Address - Country:US
Practice Address - Phone:209-573-6180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-29
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program