Provider Demographics
NPI:1164560884
Name:TINAMISAN, JULITA T
Entity Type:Individual
Prefix:DR
First Name:JULITA
Middle Name:T
Last Name:TINAMISAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3039 REDFORD PL
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92139-3650
Mailing Address - Country:US
Mailing Address - Phone:619-521-0012
Mailing Address - Fax:714-571-3560
Practice Address - Street 1:4123 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-1418
Practice Address - Country:US
Practice Address - Phone:619-521-0012
Practice Address - Fax:619-521-0961
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50539122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD50539Medicaid