Provider Demographics
NPI:1417164203
Name:PETTE, TARA MICHELE (DMD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:MICHELE
Last Name:PETTE
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 1:1075 CENTRAL PARK AVE
Mailing Address - Street 2:SUITE 410
Mailing Address - City:SCARSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10583-3242
Mailing Address - Country:US
Mailing Address - Phone:914-725-1822
Mailing Address - Fax:914-725-8828
Practice Address - Street 1:1075 CENTRAL PARK AVE
Practice Address - Street 2:SUITE 410
Practice Address - City:SCARSDALE
Practice Address - State:NY
Practice Address - Zip Code:10583-3242
Practice Address - Country:US
Practice Address - Phone:914-725-1822
Practice Address - Fax:914-725-8828
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0372181223G0001X
NY054339-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice