Provider Demographics
NPI:1568772275
Name:MATTINGLY, TARA A (DMD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:A
Last Name:MATTINGLY
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 1:1851 E BASELINE RD
Mailing Address - Street 2:103
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-1536
Mailing Address - Country:US
Mailing Address - Phone:480-558-9000
Mailing Address - Fax:
Practice Address - Street 1:1851 E BASELINE RD
Practice Address - Street 2:103
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-1536
Practice Address - Country:US
Practice Address - Phone:480-558-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-15
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011552A1223G0001X
AZD0082661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice