Provider Demographics
NPI:1508352709
Name:JOSE, TINA MARIA (DMD)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:MARIA
Last Name:JOSE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12113 W LINEBAUGH AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-1732
Mailing Address - Country:US
Mailing Address - Phone:813-530-2145
Mailing Address - Fax:
Practice Address - Street 1:12113 W LINEBAUGH AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-1732
Practice Address - Country:US
Practice Address - Phone:813-530-2145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-11
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019031782122300000X
FLDN248101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist