Provider Demographics
NPI:1144883331
Name:TSAI, NATHANIEL
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:TSAI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 BOWIE RD
Mailing Address - Street 2:
Mailing Address - City:ROLLING HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:90274-5220
Mailing Address - Country:US
Mailing Address - Phone:310-739-3988
Mailing Address - Fax:
Practice Address - Street 1:11272 MERRITT ST STE A
Practice Address - Street 2:
Practice Address - City:CASTROVILLE
Practice Address - State:CA
Practice Address - Zip Code:95012-3422
Practice Address - Country:US
Practice Address - Phone:831-633-5827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-15
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CADDS1046151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty