Provider Demographics
NPI:1417023979
Name:CAYCO-TANGCO, MIRABEL HLADKY (DDS)
Entity Type:Individual
Prefix:DR
First Name:MIRABEL
Middle Name:HLADKY
Last Name:CAYCO-TANGCO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:MIRABEL
Other - Middle Name:
Other - Last Name:CAYCO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:4145 SHADOW LN
Mailing Address - Street 2:#132
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405
Mailing Address - Country:US
Mailing Address - Phone:707-843-0504
Mailing Address - Fax:
Practice Address - Street 1:2448 GUERNEVILLE RD
Practice Address - Street 2:SUITE 1000
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-4175
Practice Address - Country:US
Practice Address - Phone:707-595-3615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54421122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist