Provider Demographics
NPI:1669716544
Name:VANDERPOOL, TARA EDEN (RDH)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:EDEN
Last Name:VANDERPOOL
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 1:6601 S RURAL RD
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85283-3747
Mailing Address - Country:US
Mailing Address - Phone:480-451-0821
Mailing Address - Fax:480-831-0563
Practice Address - Street 1:15182 N 75TH AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85381-4722
Practice Address - Country:US
Practice Address - Phone:623-878-2400
Practice Address - Fax:623-878-3151
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-16
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH007396124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist