MEDICARE: DR. ELLEN MARIE TAVARONE 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	2901017253	MI

General Provider Information

NPI Number	:	1558429605
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELLEN MARIE TAVARONE DDS

Provider Business Mailing Address
First Line	:	280 60TH ST SE STE 200
Second Line	:
City	:	KENTWOOD
State	:	MI
Zip	:	49548-9685
Country	:	US
Telephone Number	:	616-483-0750
Fax Number	:	269-649-1473

Provider Business Practice Location Address
First Line	:	280 60TH ST SE STE 200
Second Line	:
City	:	KENTWOOD
State	:	MI
Zip	:	49548-9685
Country	:	US
Telephone Number	:	616-483-0750
Fax Number	:	616-551-3683

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

Provider Enumeration Date	:	12/04/2006
Last Update Date	:	11/13/2023

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