MEDICARE: DR. TARA SKELLY PETERSON 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	D13973	MN

General Provider Information

NPI Number	:	1700376969
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TARA SKELLY PETERSON DDS

Provider Business Mailing Address
First Line	:	4663 PARKRIDGE DR
Second Line	:
City	:	EAGAN
State	:	MN
Zip	:	55123-2130
Country	:	US
Telephone Number	:	651-587-8844
Fax Number	:

Provider Business Practice Location Address
First Line	:	9042 CAHILL AVE
Second Line	:
City	:	INVER GROVE HEIGHTS
State	:	MN
Zip	:	55076-3543
Country	:	US
Telephone Number	:	651-457-8282
Fax Number	:

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

Provider Enumeration Date	:	05/14/2018
Last Update Date	:	05/14/2018

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