Provider Demographics
NPI:1174651582
Name:TAGUE, JOHN B (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:B
Last Name:TAGUE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 66TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-5537
Mailing Address - Country:US
Mailing Address - Phone:727-381-3535
Mailing Address - Fax:727-381-3033
Practice Address - Street 1:1701 66TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-5537
Practice Address - Country:US
Practice Address - Phone:727-381-3535
Practice Address - Fax:727-381-3033
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN0012800122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist