Provider Demographics
NPI:1386733269
Name:CURTIS, TINA-LISE
Entity type:Individual
Prefix:
First Name:TINA-LISE
Middle Name:
Last Name:CURTIS
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 1:378 FORBES AVENUE
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-1762
Mailing Address - Country:US
Mailing Address - Phone:415-485-0595
Mailing Address - Fax:
Practice Address - Street 1:13 PETER BEHR DR
Practice Address - Street 2:MARIN COUNTY JAIL - DENTAL HEALTH
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-5216
Practice Address - Country:US
Practice Address - Phone:415-499-6651
Practice Address - Fax:415-499-7505
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA411711223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health