Provider Demographics
NPI:1790867992
Name:TENGGREN, STUART P (DDS)
Entity Type:Individual
Prefix:DR
First Name:STUART
Middle Name:P
Last Name:TENGGREN
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 1:1105 RED TAIL WAY
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-7232
Mailing Address - Country:US
Mailing Address - Phone:805-577-7733
Mailing Address - Fax:805-577-7753
Practice Address - Street 1:1105 RED TAIL WAY
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-7232
Practice Address - Country:US
Practice Address - Phone:805-577-7733
Practice Address - Fax:805-577-7753
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2015-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA457801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice