Provider Demographics
NPI:1104200138
Name:BURGESS, TARA (DDS)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:BURGESS
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 1:2121 HEPBURN ST APT 309
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-3217
Mailing Address - Country:US
Mailing Address - Phone:281-636-1742
Mailing Address - Fax:
Practice Address - Street 1:205 PARKING WAY ST
Practice Address - Street 2:
Practice Address - City:LAKE JACKSON
Practice Address - State:TX
Practice Address - Zip Code:77566-5226
Practice Address - Country:US
Practice Address - Phone:979-297-1128
Practice Address - Fax:979-297-0956
Is Sole Proprietor?:No
Enumeration Date:2015-07-20
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX31201122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist