Provider Demographics
NPI:1679076822
Name:TADESSE TESFAMICHAEL, DDS, A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:TADESSE TESFAMICHAEL, DDS, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAD
Authorized Official - Middle Name:
Authorized Official - Last Name:TESFAMICHAEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:707-836-1202
Mailing Address - Street 1:6580 HEMBREE LN STE 255
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CA
Mailing Address - Zip Code:95492-6885
Mailing Address - Country:US
Mailing Address - Phone:707-836-1202
Mailing Address - Fax:
Practice Address - Street 1:6580 HEMBREE LN STE 255
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CA
Practice Address - Zip Code:95492-6885
Practice Address - Country:US
Practice Address - Phone:707-836-1202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-14
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty