Provider Demographics
NPI:1114288438
Name:GREEN, TARA L (DDS)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:GREEN
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 1:1013 W HIGHWAY 24
Mailing Address - Street 2:
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270-3156
Mailing Address - Country:US
Mailing Address - Phone:660-263-8181
Mailing Address - Fax:
Practice Address - Street 1:4330 MAYNARDVILLE HWY
Practice Address - Street 2:
Practice Address - City:MAYNARDVILLE
Practice Address - State:TN
Practice Address - Zip Code:37807-3618
Practice Address - Country:US
Practice Address - Phone:865-992-3849
Practice Address - Fax:865-992-5166
Is Sole Proprietor?:No
Enumeration Date:2012-06-04
Last Update Date:2019-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014027290122300000X
TNDS10914122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist