Provider Demographics
NPI:1437277266
Name:TSE, TAILEE MARIO (DDS)
Entity Type:Individual
Prefix:DR
First Name:TAILEE
Middle Name:MARIO
Last Name:TSE
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 1:2940 MONTEREY RD
Mailing Address - Street 2:
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-1734
Mailing Address - Country:US
Mailing Address - Phone:626-441-4891
Mailing Address - Fax:
Practice Address - Street 1:1060 E GREEN ST
Practice Address - Street 2:SUITE # 208
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-2413
Practice Address - Country:US
Practice Address - Phone:626-793-9109
Practice Address - Fax:626-793-9153
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32193122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-4148140OtherTAX ID NUMBER