Provider Demographics
NPI:1053566166
Name:HIROMASA FESSENDEN, TAMI (DDS)
Entity type:Individual
Prefix:DR
First Name:TAMI
Middle Name:
Last Name:HIROMASA FESSENDEN
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 1:11576 S STATE ST
Mailing Address - Street 2:SUITE 1201
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-6431
Mailing Address - Country:US
Mailing Address - Phone:801-716-7006
Mailing Address - Fax:
Practice Address - Street 1:11576 S STATE ST
Practice Address - Street 2:SUITE 1201
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-6431
Practice Address - Country:US
Practice Address - Phone:801-716-7006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-18
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6267683-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice