Provider Demographics
NPI:1255912358
Name:BEAN, TALIA
Entity type:Individual
Prefix:
First Name:TALIA
Middle Name:
Last Name:BEAN
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 1:35 ASCENSION ST APT 9
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055-4639
Mailing Address - Country:US
Mailing Address - Phone:720-496-5206
Mailing Address - Fax:
Practice Address - Street 1:172 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:WALLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07057-1286
Practice Address - Country:US
Practice Address - Phone:973-778-0918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-20
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02901600122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist