Healthcare Provider Details

I. General information

NPI: 1669716544
Provider Name (Legal Business Name): TARA EDEN VANDERPOOL RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2012
Last Update Date: 11/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15182 N 75TH AVE SUITE 120
PEORIA AZ
85381-4722
US

IV. Provider business mailing address

6601 S RURAL RD
TEMPE AZ
85283-3747
US

V. Phone/Fax

Practice location:
  • Phone: 623-878-2400
  • Fax: 623-878-3151
Mailing address:
  • Phone: 480-451-0821
  • Fax: 480-831-0563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberH007396
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: