Provider Demographics
NPI:1447902226
Name:TITTLE, MIA JONELLE (DDS)
Entity type:Individual
Prefix:DR
First Name:MIA
Middle Name:JONELLE
Last Name:TITTLE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5402 STONEHURST DR
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553-9725
Mailing Address - Country:US
Mailing Address - Phone:925-822-2491
Mailing Address - Fax:
Practice Address - Street 1:401 GREGORY LN STE 118
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-2851
Practice Address - Country:US
Practice Address - Phone:925-676-3388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-22
Last Update Date:2022-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1042441223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty