Provider Demographics
NPI:1760540942
Name:TASSARA, GIANCARLO G (DDS)
Entity Type:Individual
Prefix:
First Name:GIANCARLO
Middle Name:G
Last Name:TASSARA
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 1:1111 W TOWN AND COUNTRY RD STE 46
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4667
Mailing Address - Country:US
Mailing Address - Phone:657-235-8033
Mailing Address - Fax:657-247-0444
Practice Address - Street 1:1111 W TOWN AND COUNTRY RD STE 46
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4667
Practice Address - Country:US
Practice Address - Phone:657-235-8033
Practice Address - Fax:657-247-0444
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA569321223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics