Provider Demographics
NPI:1437115169
Name:HILLEARY, TARA (DDS)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:HILLEARY
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 1:5861 MASON-DIXON HIGHWAY
Mailing Address - Street 2:BOX 72
Mailing Address - City:BLACKSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26521
Mailing Address - Country:US
Mailing Address - Phone:304-432-8211
Mailing Address - Fax:304-432-8213
Practice Address - Street 1:5861 MASON-DIXON HIGHWAY
Practice Address - Street 2:BOX 72
Practice Address - City:BLACKSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26521
Practice Address - Country:US
Practice Address - Phone:304-432-8211
Practice Address - Fax:304-432-8213
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3638122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810000893Medicaid