Provider Demographics
NPI:1437401619
Name:BOSHNACK, TARA BROOKE (DDS)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:BROOKE
Last Name:BOSHNACK
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 1:2866 LOVELAND DR
Mailing Address - Street 2:UNIT 2036
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89109-0227
Mailing Address - Country:US
Mailing Address - Phone:516-509-5031
Mailing Address - Fax:
Practice Address - Street 1:4955 S DURANGO DR
Practice Address - Street 2:201
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89113
Practice Address - Country:US
Practice Address - Phone:702-933-7275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-11
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6271122300000X
FLDN19585122300000X
NY056092122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist