Provider Demographics
NPI:1750934956
Name:TULLY, NATHAN (DMD)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:TULLY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18511 SHERMAN WAY
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-4213
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18511 SHERMAN WAY
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-4213
Practice Address - Country:US
Practice Address - Phone:818-748-9726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-17
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1037041223G0001X, 122300000X
CA1037041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice