Healthcare Provider Details

I. General information

NPI: 1083987556
Provider Name (Legal Business Name): AMY R. TART
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2012
Last Update Date: 02/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4058 WILLOWS RD
ALPINE CA
91901-1668
US

IV. Provider business mailing address

1910 TAVERN RD
ALPINE CA
91901-3126
US

V. Phone/Fax

Practice location:
  • Phone: 619-445-1188
  • Fax:
Mailing address:
  • Phone: 619-722-1270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number21818
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number7055
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: