Provider Demographics
NPI:1376610675
Name:TINGZON, MARDI ANNE (DDS)
Entity Type:Individual
Prefix:
First Name:MARDI
Middle Name:ANNE
Last Name:TINGZON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2172 BLACKBERRY DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-1102
Mailing Address - Country:US
Mailing Address - Phone:630-208-9331
Mailing Address - Fax:630-208-9398
Practice Address - Street 1:2172 BLACKBERRY DR
Practice Address - Street 2:SUITE 201
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-1102
Practice Address - Country:US
Practice Address - Phone:630-208-9331
Practice Address - Fax:630-208-9398
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019022400122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist