Provider Demographics
NPI:1285161323
Name:TIN DENTAL SPECIALTY GROUP A PROFESSIONAL DENTAL CORP
Entity type:Organization
Organization Name:TIN DENTAL SPECIALTY GROUP A PROFESSIONAL DENTAL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:TIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:415-218-3866
Mailing Address - Street 1:1436 CLARKE ST
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-3635
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1436 CLARKE ST
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-3635
Practice Address - Country:US
Practice Address - Phone:415-987-0260
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-19
Last Update Date:2017-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA37744OtherDENTICAL