Provider Demographics
NPI:1134601669
Name:TENGCO, DERRICK GLEN (DMD)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:GLEN
Last Name:TENGCO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 NASSAU ST APT 909
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02111-1554
Mailing Address - Country:US
Mailing Address - Phone:609-658-3233
Mailing Address - Fax:
Practice Address - Street 1:314 ESSEX ST
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01840-1411
Practice Address - Country:US
Practice Address - Phone:605-714-5114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1858105122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist