Provider Demographics
NPI:1013560598
Name:TANJAYA, JUSTINE (DDS, MS, PHD)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:
Last Name:TANJAYA
Suffix:
Gender:F
Credentials:DDS, MS, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3790 CEDARPLAZA LN APT 2324
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75209-6379
Mailing Address - Country:US
Mailing Address - Phone:619-549-6520
Mailing Address - Fax:
Practice Address - Street 1:1604 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76010-4724
Practice Address - Country:US
Practice Address - Phone:619-549-6520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX355401223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics