Healthcare Provider Details

I. General information

NPI: 1417868092
Provider Name (Legal Business Name): ENRIQUE TAMAYO D.D.S., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 S BROADWAY STE 103
LOS ANGELES CA
90037-2792
US

IV. Provider business mailing address

4400 S BROADWAY STE 103
LOS ANGELES CA
90037-2792
US

V. Phone/Fax

Practice location:
  • Phone: 323-233-9400
  • Fax: 323-233-9977
Mailing address:
  • Phone: 323-233-9400
  • Fax: 323-233-9977

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateNULL

VIII. Authorized Official

Name: ENRIQUE TAMAYO
Title or Position: OWNER
Credential: D.D.S.
Phone: 323-233-9400