Provider Demographics
NPI:1619401890
Name:TAVAREZ MONEGRO, CHANTAL (DDS)
Entity Type:Individual
Prefix:
First Name:CHANTAL
Middle Name:
Last Name:TAVAREZ MONEGRO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1924 UNIVERSITY AVE APT 1B
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-4413
Mailing Address - Country:US
Mailing Address - Phone:413-355-1321
Mailing Address - Fax:
Practice Address - Street 1:1924 UNIVERSITY AVE APT 1B
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10453-4413
Practice Address - Country:US
Practice Address - Phone:413-355-1321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-14
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY059887-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice