Provider Demographics
NPI:1902340847
Name:TAN, CAROLYN ONG (DDS)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:ONG
Last Name:TAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:CAROLYN
Other - Middle Name:R
Other - Last Name:ONG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:828 S MOONEY BLVD
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93277-2212
Mailing Address - Country:US
Mailing Address - Phone:559-802-4300
Mailing Address - Fax:
Practice Address - Street 1:828 S MOONEY BLVD
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-2212
Practice Address - Country:US
Practice Address - Phone:559-802-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-12
Last Update Date:2017-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA592011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice