Provider Demographics
NPI:1194859199
Name:JENNINGS, TARA LYNN (DDS)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LYNN
Last Name:JENNINGS
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 1:3216 BUSINESS PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54481
Mailing Address - Country:US
Mailing Address - Phone:715-341-7171
Mailing Address - Fax:715-341-5160
Practice Address - Street 1:3216 BUSINESS PARK DR
Practice Address - Street 2:
Practice Address - City:STEVENS POINT
Practice Address - State:WI
Practice Address - Zip Code:54481-8838
Practice Address - Country:US
Practice Address - Phone:715-341-7171
Practice Address - Fax:715-341-5160
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5392122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist