Provider Demographics
NPI:1619014701
Name:ADAMS, TABATHA MANN
Entity Type:Individual
Prefix:DR
First Name:TABATHA
Middle Name:MANN
Last Name:ADAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:TABATHA
Other - Middle Name:
Other - Last Name:ADAMS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DMD
Mailing Address - Street 1:PO BOX 437169
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40253-7169
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1508 OXFORD DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-9266
Practice Address - Country:US
Practice Address - Phone:502-863-0880
Practice Address - Fax:502-867-7363
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY72161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60072162Medicaid