Provider Demographics
NPI:1245605542
Name:TAMARA EATON DDS PC
Entity Type:Organization
Organization Name:TAMARA EATON DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILDE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-210-3495
Mailing Address - Street 1:1213 E COOLSPRING AVE
Mailing Address - Street 2:
Mailing Address - City:MICHIGAN CITY
Mailing Address - State:IN
Mailing Address - Zip Code:46360-6319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1213 E COOLSPRING AVE
Practice Address - Street 2:
Practice Address - City:MICHIGAN CITY
Practice Address - State:IN
Practice Address - Zip Code:46360-6319
Practice Address - Country:US
Practice Address - Phone:219-872-9151
Practice Address - Fax:219-873-3341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-11
Last Update Date:2015-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009857A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200384300AMedicaid