Provider Demographics
NPI:1710580758
Name:HUEBNER LOESER, TATJANA (CRDH)
Entity Type:Individual
Prefix:
First Name:TATJANA
Middle Name:
Last Name:HUEBNER LOESER
Suffix:
Gender:F
Credentials:CRDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:378 W GRANADA BLVD
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-6274
Mailing Address - Country:US
Mailing Address - Phone:386-672-5595
Mailing Address - Fax:386-672-5595
Practice Address - Street 1:378 W GRANADA BLVD
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-6274
Practice Address - Country:US
Practice Address - Phone:386-672-5595
Practice Address - Fax:386-672-5597
Is Sole Proprietor?:No
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDH27080124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist