Provider Demographics
NPI:1184197477
Name:ZALESAK, TARA L (RDH)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:ZALESAK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 E WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53703-2917
Mailing Address - Country:US
Mailing Address - Phone:608-665-2752
Mailing Address - Fax:
Practice Address - Street 1:630 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53703-2917
Practice Address - Country:US
Practice Address - Phone:608-665-2752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-09
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1003169124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist