Provider Demographics
NPI:1134523103
Name:TAN, TINA S (DMD)
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:S
Last Name:TAN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 S EMERSON ST
Mailing Address - Street 2:
Mailing Address - City:MT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-3247
Mailing Address - Country:US
Mailing Address - Phone:847-577-7500
Mailing Address - Fax:
Practice Address - Street 1:214 S EMERSON ST
Practice Address - Street 2:
Practice Address - City:MT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-3247
Practice Address - Country:US
Practice Address - Phone:847-577-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-20
Last Update Date:2014-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-0200601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice