Provider Demographics
NPI:1689883571
Name:QUAN, TIM (DDS)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:QUAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8848 CLARINDA AVE.
Mailing Address - Street 2:
Mailing Address - City:PICO RIVERA
Mailing Address - State:CA
Mailing Address - Zip Code:90660
Mailing Address - Country:US
Mailing Address - Phone:818-399-6051
Mailing Address - Fax:
Practice Address - Street 1:6400 VAN NUYS BLVD.
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401
Practice Address - Country:US
Practice Address - Phone:818-399-6051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADL035449122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist