Provider Demographics
NPI:1518084946
Name:DENNIS, TIA (DDS)
Entity Type:Individual
Prefix:DR
First Name:TIA
Middle Name:
Last Name:DENNIS
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:P.O. BOX 5845
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92412-5845
Mailing Address - Country:US
Mailing Address - Phone:909-709-0802
Mailing Address - Fax:909-980-8072
Practice Address - Street 1:8325 HAVEN AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3894
Practice Address - Country:US
Practice Address - Phone:909-989-3566
Practice Address - Fax:909-989-3566
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2010-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA537841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice