Provider Demographics
NPI:1457497414
Name:BROOKS, TARA LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:LYNN
Last Name:BROOKS
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 1:1046 RIDGE AVE SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30315-1640
Mailing Address - Country:US
Mailing Address - Phone:404-688-1350
Mailing Address - Fax:
Practice Address - Street 1:1536 EISENHOWER PKWY
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31206-3130
Practice Address - Country:US
Practice Address - Phone:478-781-4333
Practice Address - Fax:478-781-4331
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA117441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice