Provider Demographics
NPI:1124749692
Name:ALFONSO, SHARYNNE ISYS TABAL (DDS)
Entity type:Individual
Prefix:DR
First Name:SHARYNNE ISYS
Middle Name:TABAL
Last Name:ALFONSO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1868 MEEKS BAY DR
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-1651
Mailing Address - Country:US
Mailing Address - Phone:619-816-8862
Mailing Address - Fax:
Practice Address - Street 1:6755 MIRA MESA BLVD STE 142
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-4311
Practice Address - Country:US
Practice Address - Phone:858-457-7747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-02
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA107935122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist