Provider Demographics
NPI:1639141609
Name:TAN, PETER M (DDS MSHS)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:M
Last Name:TAN
Suffix:
Gender:M
Credentials:DDS MSHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 THOMAS JOHNSON DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21702
Mailing Address - Country:US
Mailing Address - Phone:301-694-2300
Mailing Address - Fax:301-694-7372
Practice Address - Street 1:68 THOMAS JOHNSON DR
Practice Address - Street 2:SUITE A
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702
Practice Address - Country:US
Practice Address - Phone:301-694-2300
Practice Address - Fax:301-694-7372
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD08276204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
37385OtherDENTAL BENEFIT PROVIDERS
952901OtherUCCI
410662OtherMAMSI
60443OtherTRICARE PRIME
DE94OtherBCBS DENTAL
733L585DMedicare ID - Type Unspecified
DE94OtherBCBS DENTAL