Provider Demographics
NPI:1649965609
Name:CALLE MORA, TANYA SABRINA
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:SABRINA
Last Name:CALLE MORA
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 1:33 HILLCREST PARK APT A
Mailing Address - Street 2:
Mailing Address - City:SOUTH HADLEY
Mailing Address - State:MA
Mailing Address - Zip Code:01075-2976
Mailing Address - Country:US
Mailing Address - Phone:407-415-8583
Mailing Address - Fax:
Practice Address - Street 1:505 FRONT ST
Practice Address - Street 2:
Practice Address - City:CHICOPEE
Practice Address - State:MA
Practice Address - Zip Code:01013-3140
Practice Address - Country:US
Practice Address - Phone:413-420-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-06
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MADN10000132122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program