Provider Demographics
NPI:1598921827
Name:ERICSON, TARA HELEN (DDS)
Entity Type:Individual
Prefix:MISS
First Name:TARA
Middle Name:HELEN
Last Name:ERICSON
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 1:1203 OLD NORTH KENTUCKY ST
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:37763-2028
Mailing Address - Country:US
Mailing Address - Phone:865-717-3586
Mailing Address - Fax:
Practice Address - Street 1:1212 NORTH KENTUCKY ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:TN
Practice Address - Zip Code:37763-2328
Practice Address - Country:US
Practice Address - Phone:865-717-3586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2012-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA57389122300000X
TN9108122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1518433Medicaid