Provider Demographics
NPI:1700976461
Name:MARILOU C. TAN, D.D.S. PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:MARILOU C. TAN, D.D.S. PROFESSIONAL DENTAL CORPORATION
Other - Org Name:PIONEER FAMILY DENTAL PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARILOU
Authorized Official - Middle Name:C
Authorized Official - Last Name:TAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-689-3310
Mailing Address - Street 1:7850 STOCKTON BLVD
Mailing Address - Street 2:SUITE #160
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-4319
Mailing Address - Country:US
Mailing Address - Phone:916-689-3310
Mailing Address - Fax:
Practice Address - Street 1:7850 STOCKTON BLVD
Practice Address - Street 2:SUITE #160
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-4319
Practice Address - Country:US
Practice Address - Phone:916-689-3310
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty