Provider Demographics
NPI:1265874663
Name:LARUE, TAMARA (RDH)
Entity type:Individual
Prefix:MS
First Name:TAMARA
Middle Name:
Last Name:LARUE
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 DOMEDION AVE
Mailing Address - Street 2:LOWER
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14211-2109
Mailing Address - Country:US
Mailing Address - Phone:716-533-0393
Mailing Address - Fax:
Practice Address - Street 1:222 RICHMOND AVE
Practice Address - Street 2:130B
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14020-1227
Practice Address - Country:US
Practice Address - Phone:585-297-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-25
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024890124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist