Provider Demographics
NPI:1093070948
Name:TANAKA, CARISSA MARIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:CARISSA
Middle Name:MARIE
Last Name:TANAKA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:CARISSA
Other - Middle Name:MARIE
Other - Last Name:DAINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:141 CONVERSE AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06450-3451
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:74 MAIN ST
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06451-5119
Practice Address - Country:US
Practice Address - Phone:203-235-0121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-06
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT109691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice