Healthcare Provider Details

I. General information

NPI: 1417164203
Provider Name (Legal Business Name): TARA MICHELE PETTE DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 06/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 CENTRAL PARK AVE SUITE 410
SCARSDALE NY
10583-3242
US

IV. Provider business mailing address

1075 CENTRAL PARK AVE SUITE 410
SCARSDALE NY
10583-3242
US

V. Phone/Fax

Practice location:
  • Phone: 914-725-1822
  • Fax: 914-725-8828
Mailing address:
  • Phone: 914-725-1822
  • Fax: 914-725-8828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number054339-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS037218
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: