Healthcare Provider Details

I. General information

NPI: 1437231586
Provider Name (Legal Business Name): TENGGREN DENTAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 N WILSON ST STE D
NIPOMO CA
93444-7830
US

IV. Provider business mailing address

7349 ROCKY TOP CIR
MOORPARK CA
93021-1299
US

V. Phone/Fax

Practice location:
  • Phone: 805-929-3219
  • Fax: 805-929-4798
Mailing address:
  • Phone: 805-217-8138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number45780
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. STUART P TENGGREN
Title or Position: PRESIDENT
Credential: DDS
Phone: 805-217-8138