Provider Demographics
NPI:1225480544
Name:TATRO, STACEY (DMD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:TATRO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11043 BROADWAY STE A
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-8834
Mailing Address - Country:US
Mailing Address - Phone:219-663-4200
Mailing Address - Fax:
Practice Address - Street 1:11043 BROADWAY STE A
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-8834
Practice Address - Country:US
Practice Address - Phone:219-663-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL091.030688122300000X
IN12013335A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist