Provider Demographics
NPI:1700376969
Name:PETERSON, TARA SKELLY (DDS)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:SKELLY
Last Name:PETERSON
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 1:4663 PARKRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-2130
Mailing Address - Country:US
Mailing Address - Phone:651-587-8844
Mailing Address - Fax:
Practice Address - Street 1:9042 CAHILL AVE
Practice Address - Street 2:
Practice Address - City:INVER GROVE HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55076-3543
Practice Address - Country:US
Practice Address - Phone:651-457-8282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND13973122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist