Provider Demographics
NPI:1326172842
Name:DECANO, TOMMIE GLENN B (DDS)
Entity Type:Individual
Prefix:DR
First Name:TOMMIE GLENN
Middle Name:B
Last Name:DECANO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15801 S 48TH ST
Mailing Address - Street 2:# 1074
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85048-0807
Mailing Address - Country:US
Mailing Address - Phone:909-919-4334
Mailing Address - Fax:
Practice Address - Street 1:1905 E MCKELLIPS RD
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85203-2865
Practice Address - Country:US
Practice Address - Phone:480-649-1949
Practice Address - Fax:480-649-0617
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6306122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist