Healthcare Provider Details

I. General information

NPI: 1225480544
Provider Name (Legal Business Name): STACEY TATRO DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2016
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1123 JOLIET ST
DYER IN
46311-1926
US

IV. Provider business mailing address

1123 JOLIET ST
DYER IN
46311-1926
US

V. Phone/Fax

Practice location:
  • Phone: 219-225-2294
  • Fax:
Mailing address:
  • Phone: 219-225-2294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number091.030688
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12013335A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: