Healthcare Provider Details

I. General information

NPI: 1558429605
Provider Name (Legal Business Name): ELLEN MARIE TAVARONE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2060 DIVISION AVE S
GRAND RAPIDS MI
49507-3029
US

IV. Provider business mailing address

2060 DIVISION AVE S
GRAND RAPIDS MI
49507-3029
US

V. Phone/Fax

Practice location:
  • Phone: 616-475-8446
  • Fax: 616-475-1272
Mailing address:
  • Phone: 616-475-8446
  • Fax: 616-475-1272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901017253
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: