MEDICARE: DR. ENRIQUE TAMAYO DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	52474	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811033699
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ENRIQUE TAMAYO DDS

Provider Business Mailing Address
First Line	:	4400 S BROADWAY STE 103
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90037-2792
Country	:	US
Telephone Number	:	323-233-9400
Fax Number	:	323-233-9977

Provider Business Practice Location Address
First Line	:	4400 S BROADWAY STE 103
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90037-2792
Country	:	US
Telephone Number	:	323-233-9400
Fax Number	:	323-233-9977

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	03/17/2018

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