Provider Demographics
NPI:1528643632
Name:TAYAG, EMMANUEL MARASIGAN
Entity type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:MARASIGAN
Last Name:TAYAG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 S GREENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-5515
Mailing Address - Country:US
Mailing Address - Phone:310-216-8585
Mailing Address - Fax:
Practice Address - Street 1:4000 LA RICA AVE STE D
Practice Address - Street 2:
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-3163
Practice Address - Country:US
Practice Address - Phone:626-430-9171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-10
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62115126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA62115Medicaid