Provider Demographics
NPI:1417214008
Name:VOLLEBREGT, TAMARA L (RDHAP)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:L
Last Name:VOLLEBREGT
Suffix:
Gender:F
Credentials:RDHAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1142 S DIAMOND BAR BLVD # 162
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-2203
Mailing Address - Country:US
Mailing Address - Phone:909-861-0280
Mailing Address - Fax:909-861-6951
Practice Address - Street 1:1142 S DIAMOND BAR BLVD # 162
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-2203
Practice Address - Country:US
Practice Address - Phone:909-861-0280
Practice Address - Fax:909-861-6951
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-19
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDHAP385124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist