Provider Demographics
NPI:1811033699
Name:TAMAYO, ENRIQUE (DDS)
Entity Type:Individual
Prefix:DR
First Name:ENRIQUE
Middle Name:
Last Name:TAMAYO
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 1:4400 S BROADWAY STE 103
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90037-2792
Mailing Address - Country:US
Mailing Address - Phone:323-233-9400
Mailing Address - Fax:323-233-9977
Practice Address - Street 1:4400 S BROADWAY STE 103
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90037-2792
Practice Address - Country:US
Practice Address - Phone:323-233-9400
Practice Address - Fax:323-233-9977
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA524741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD52474Medicaid