Provider Demographics
NPI:1467028951
Name:TUNGGADJAJA, NATANIA STACY (DDS)
Entity type:Individual
Prefix:DR
First Name:NATANIA
Middle Name:STACY
Last Name:TUNGGADJAJA
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 1:2828 OLD SPANISH TRL APT 409
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-2256
Mailing Address - Country:US
Mailing Address - Phone:713-569-6985
Mailing Address - Fax:
Practice Address - Street 1:3244 MERIDIANA PKWY STE 105
Practice Address - Street 2:
Practice Address - City:ROSHARON
Practice Address - State:TX
Practice Address - Zip Code:77583-3385
Practice Address - Country:US
Practice Address - Phone:281-909-0202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-03
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX376841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty