Healthcare Provider Details

I. General information

NPI: 1750934956
Provider Name (Legal Business Name): NATHAN TULLY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2019
Last Update Date: 09/21/2026
Certification Date:
Deactivation Date: 09/08/2026
Reactivation Date: 09/21/2026

III. Provider practice location address

18511 SHERMAN WAY
RESEDA CA
91335-4213
US

IV. Provider business mailing address

18511 SHERMAN WAY
RESEDA CA
91335-4213
US

V. Phone/Fax

Practice location:
  • Phone: 818-748-9726
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS103704
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDDS103704
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number103704
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: