Provider Demographics
NPI:1508419185
Name:TANG, JOHANNA MARY (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHANNA
Middle Name:MARY
Last Name:TANG
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 1:257 W 117TH ST APT 4G
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10026-2187
Mailing Address - Country:US
Mailing Address - Phone:630-618-8939
Mailing Address - Fax:
Practice Address - Street 1:76 HOWE AVE
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-4160
Practice Address - Country:US
Practice Address - Phone:203-924-4488
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT125851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice