Provider Demographics
NPI:1669851564
Name:WAN, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:WAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 CENTER DR
Mailing Address - Street 2:STE 101
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-2502
Mailing Address - Country:US
Mailing Address - Phone:909-374-5173
Mailing Address - Fax:
Practice Address - Street 1:709 CENTER DR
Practice Address - Street 2:STE 101
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-2502
Practice Address - Country:US
Practice Address - Phone:909-374-5173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-26
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA100840122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist