Provider Demographics
NPI:1194417071
Name:TAMANG, SUJIKA
Entity type:Individual
Prefix:
First Name:SUJIKA
Middle Name:
Last Name:TAMANG
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 1:232 RIVERWOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536
Mailing Address - Country:US
Mailing Address - Phone:806-516-4333
Mailing Address - Fax:
Practice Address - Street 1:2670 S FERDON BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536
Practice Address - Country:US
Practice Address - Phone:850-634-0748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL280261223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program