Healthcare Provider Details

I. General information

NPI: 1114554284
Provider Name (Legal Business Name): TARA VATTADI DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 11/17/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 MARIPOSA AVE
WATSONVILLE CA
95076-2660
US

IV. Provider business mailing address

98 MARIPOSA AVE
WATSONVILLE CA
95076-2660
US

V. Phone/Fax

Practice location:
  • Phone: 831-724-1003
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number019032705
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number107043
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: