Provider Demographics
NPI:1467504472
Name:BRODERICK, TARA KIMBERLY (DMD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:KIMBERLY
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MRS
Other - First Name:TARA
Other - Middle Name:KIMBERLY
Other - Last Name:BRODERICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:645 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HACKENSACK
Mailing Address - State:NJ
Mailing Address - Zip Code:07601-4712
Mailing Address - Country:US
Mailing Address - Phone:201-488-8300
Mailing Address - Fax:201-488-5953
Practice Address - Street 1:645 MAIN ST
Practice Address - Street 2:
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-4712
Practice Address - Country:US
Practice Address - Phone:201-488-8300
Practice Address - Fax:201-488-5953
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice