Provider Demographics
NPI:1841502523
Name:TANDON, MARY COLLEEN (DDS)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:COLLEEN
Last Name:TANDON
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 1:1166 K ST
Mailing Address - Street 2:
Mailing Address - City:BRAWLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92227-2737
Mailing Address - Country:US
Mailing Address - Phone:760-344-9951
Mailing Address - Fax:760-344-6128
Practice Address - Street 1:1166 K ST
Practice Address - Street 2:
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227-2737
Practice Address - Country:US
Practice Address - Phone:760-344-9951
Practice Address - Fax:760-344-6128
Is Sole Proprietor?:No
Enumeration Date:2010-07-09
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA087241223G0001X
AZD0085381223G0001X
CA59754122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice