Healthcare Provider Details

I. General information

NPI: 1275068025
Provider Name (Legal Business Name): E M TASH DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2017
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

864 N HACIENDA BLVD
LA PUENTE CA
91744-2847
US

IV. Provider business mailing address

864 N HACIENDA BLVD
LA PUENTE CA
91744-2847
US

V. Phone/Fax

Practice location:
  • Phone: 626-333-8166
  • Fax: 626-333-9879
Mailing address:
  • Phone: 626-333-8166
  • Fax: 626-333-9879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number47422
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number47422
License Number StateCA

VIII. Authorized Official

Name: DR. EDMOND TASH
Title or Position: PRESIDENT
Credential: DDS
Phone: 626-333-8166