Provider Demographics
NPI:1558781393
Name:GITHU, TARISAI (DDS)
Entity Type:Individual
Prefix:DR
First Name:TARISAI
Middle Name:
Last Name:GITHU
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 1:2937 S BAY STAR WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-3094
Mailing Address - Country:US
Mailing Address - Phone:267-455-1373
Mailing Address - Fax:
Practice Address - Street 1:1378 N MERIDIAN RD
Practice Address - Street 2:
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634-1686
Practice Address - Country:US
Practice Address - Phone:208-606-4816
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-20
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0407041223G0001X
IDD-4990-PD1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral Practice