Provider Demographics
NPI:1801993050
Name:TESFAMICHAEL, TADESSE (DDS)
Entity type:Individual
Prefix:
First Name:TADESSE
Middle Name:
Last Name:TESFAMICHAEL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 N BASCOM AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-1400
Mailing Address - Country:US
Mailing Address - Phone:408-247-8001
Mailing Address - Fax:408-247-8004
Practice Address - Street 1:920 N BASCOM AVE STE 1
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1400
Practice Address - Country:US
Practice Address - Phone:408-247-8001
Practice Address - Fax:408-247-8004
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40317122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist