Provider Demographics
NPI:1255010732
Name:TILLERO IRAUSQUIN, HADA MARIANGELA
Entity type:Individual
Prefix:
First Name:HADA
Middle Name:MARIANGELA
Last Name:TILLERO IRAUSQUIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10623 ERIC CT
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-9049
Mailing Address - Country:US
Mailing Address - Phone:407-535-9881
Mailing Address - Fax:
Practice Address - Street 1:110 N TILLOTSON AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-3987
Practice Address - Country:US
Practice Address - Phone:765-288-1928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-12
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12014102A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist