Provider Demographics
NPI:1851449011
Name:MOUSTIS, TARA (DDS)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:
Last Name:MOUSTIS
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 1:17037 OAK PARK AVE
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-2776
Mailing Address - Country:US
Mailing Address - Phone:708-532-8322
Mailing Address - Fax:708-532-9210
Practice Address - Street 1:17037 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-2776
Practice Address - Country:US
Practice Address - Phone:708-532-8322
Practice Address - Fax:708-532-9210
Is Sole Proprietor?:No
Enumeration Date:2007-01-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice