Healthcare Provider Details

I. General information

NPI: 1649965609
Provider Name (Legal Business Name): TANYA SABRINA CALLE MORA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2023
Last Update Date: 05/23/2024
Certification Date: 05/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 FRONT ST
CHICOPEE MA
01013-3140
US

IV. Provider business mailing address

33 HILLCREST PARK APT A
SOUTH HADLEY MA
01075-2976
US

V. Phone/Fax

Practice location:
  • Phone: 413-420-2222
  • Fax:
Mailing address:
  • Phone: 407-415-8583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN10000132
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: