Provider Demographics
NPI:1073891925
Name:PURSELY, TARA C (DMD)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:C
Last Name:PURSELY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3720 HARDY ST
Mailing Address - Street 2:SUITE 23
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1550
Mailing Address - Country:US
Mailing Address - Phone:601-264-2779
Mailing Address - Fax:
Practice Address - Street 1:1090 NORTHCHASE PKWY SE
Practice Address - Street 2:SUITE 290
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-6405
Practice Address - Country:US
Practice Address - Phone:770-916-9526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-26
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS3608-11122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist