1417023979 NPI number — DR. MIRABEL HLADKY CAYCO-TANGCO DDS

Table of content: DR. MIRABEL HLADKY CAYCO-TANGCO DDS (NPI 1417023979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417023979 NPI number — DR. MIRABEL HLADKY CAYCO-TANGCO DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CAYCO-TANGCO
Provider First Name:
MIRABEL
Provider Middle Name:
HLADKY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CAYCO
Provider Other First Name:
MIRABEL
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1417023979
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4145 SHADOW LN
Provider Second Line Business Mailing Address:
#132
Provider Business Mailing Address City Name:
SANTA ROSA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
707-843-0504
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2448 GUERNEVILLE RD
Provider Second Line Business Practice Location Address:
SUITE 1000
Provider Business Practice Location Address City Name:
SANTA ROSA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95403-4175
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-595-3615
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/28/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  54421 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)