MEDICARE: DR. ANITA R TA DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	30-02-0193	OH

General Provider Information

NPI Number	:	1023014404
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ANITA R TA DDS

Provider Business Mailing Address
First Line	:	2400 WALES AVE NW
Second Line	:	STE B
City	:	MASSILLON
State	:	OH
Zip	:	44646-2366
Country	:	US
Telephone Number	:	330-833-2619
Fax Number	:	330-833-6987

Provider Business Practice Location Address
First Line	:	2400 WALES AVE NW
Second Line	:	STE B
City	:	MASSILLON
State	:	OH
Zip	:	44646-2366
Country	:	US
Telephone Number	:	330-833-2619
Fax Number	:	330-833-6987

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	07/08/2007

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