Healthcare Provider Details

I. General information

NPI: 1467060897
Provider Name (Legal Business Name): TARA LYNN GRZETIC DMD, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2020
Last Update Date: 01/11/2023
Certification Date: 01/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 FOXFIELD RD
ST CHARLES IL
60174-1442
US

IV. Provider business mailing address

720 N OLD WORLD 3RD ST APT 807
MILWAUKEE WI
53203-2245
US

V. Phone/Fax

Practice location:
  • Phone: 630-584-6555
  • Fax:
Mailing address:
  • Phone: 630-715-3377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0000011264
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: