Provider Demographics
NPI:1467060897
Name:GRZETIC, TARA LYNN (DMD, MS)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:LYNN
Last Name:GRZETIC
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:720 N OLD WORLD 3RD ST APT 807
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53203-2245
Mailing Address - Country:US
Mailing Address - Phone:630-715-3377
Mailing Address - Fax:
Practice Address - Street 1:2055 FOXFIELD RD
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1442
Practice Address - Country:US
Practice Address - Phone:630-584-6555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-22
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000112641223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics