Provider Demographics
NPI:1467161125
Name:SHEPHERD, TARA L (RDH)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:L
Last Name:SHEPHERD
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8999 SUNRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-5777
Mailing Address - Country:US
Mailing Address - Phone:423-883-7123
Mailing Address - Fax:
Practice Address - Street 1:9409 APISON PIKE STE 119
Practice Address - Street 2:
Practice Address - City:OOLTEWAH
Practice Address - State:TN
Practice Address - Zip Code:37363-7283
Practice Address - Country:US
Practice Address - Phone:423-648-4884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-21
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3920124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist