Provider Demographics
NPI:1003150384
Name:TAGATAC, MARELLA JO (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARELLA
Middle Name:JO
Last Name:TAGATAC
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8333 BRAESMAIN DR
Mailing Address - Street 2:# 1404
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77025-2940
Mailing Address - Country:US
Mailing Address - Phone:858-354-6854
Mailing Address - Fax:
Practice Address - Street 1:8333 BRAESMAIN DR
Practice Address - Street 2:# 1404
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77025-2940
Practice Address - Country:US
Practice Address - Phone:858-354-6854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX284491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice