Provider Demographics
NPI:1427691112
Name:TANDY, ABIGAIL COLEEN
Entity type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:COLEEN
Last Name:TANDY
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 1:1102 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097-2267
Mailing Address - Country:US
Mailing Address - Phone:530-905-0760
Mailing Address - Fax:
Practice Address - Street 1:1519 S OREGON ST
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-3425
Practice Address - Country:US
Practice Address - Phone:530-842-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-24
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARDH27632124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist