Provider Demographics
NPI:1720128812
Name:TAGLE, HENRY JOSEPH III (DMD)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:JOSEPH
Last Name:TAGLE
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1600 W. UNIVESITY AVE STE 103
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001
Mailing Address - Country:US
Mailing Address - Phone:928-774-4400
Mailing Address - Fax:928-774-5436
Practice Address - Street 1:1600 W. UNIVESITY AVE STE 103
Practice Address - Street 2:SUITE 102
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001
Practice Address - Country:US
Practice Address - Phone:928-774-4400
Practice Address - Fax:928-774-5436
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ65311223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ860875508OtherTAX ID
AZ6531OtherLICENSE NUMBER