=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669716544
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TARA EDEN VANDERPOOL RDH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2012
-----------------------------------------------------
Last Update Date | 11/16/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 15182 N 75TH AVE SUITE 120
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85381-4722
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-878-2400
-----------------------------------------------------
Fax | 623-878-3151
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6601 S RURAL RD
-----------------------------------------------------
City | TEMPE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85283-3747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 480-451-0821
-----------------------------------------------------
Fax | 480-831-0563
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | H007396
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------