Provider Demographics
NPI:1689788093
Name:TAN, JENNIFER (DDS)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:TAN
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 1:86-260 FARRINGTON HWY
Mailing Address - Street 2:
Mailing Address - City:WAIANAE
Mailing Address - State:HI
Mailing Address - Zip Code:96792-3128
Mailing Address - Country:US
Mailing Address - Phone:808-697-3300
Mailing Address - Fax:808-696-7093
Practice Address - Street 1:86-260 FARRINGTON HWY
Practice Address - Street 2:
Practice Address - City:WAIANAE
Practice Address - State:HI
Practice Address - Zip Code:96792-3128
Practice Address - Country:US
Practice Address - Phone:808-697-3300
Practice Address - Fax:808-696-7093
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053093122300000X
HIDT-2318122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1932082OtherUNITED CONCORDIA
AKDD3780Medicaid