Provider Demographics
NPI:1639269053
Name:WORTHEN, TAMARA BLISS (DDS)
Entity Type:Individual
Prefix:DR
First Name:TAMARA
Middle Name:BLISS
Last Name:WORTHEN
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 1:1103 WALNUT DR
Mailing Address - Street 2:PEDIATRIC DENTAL ASSOCIATES PC
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-2354
Mailing Address - Country:US
Mailing Address - Phone:580-226-6290
Mailing Address - Fax:580-223-4381
Practice Address - Street 1:1103 WALNUT DR
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-2354
Practice Address - Country:US
Practice Address - Phone:580-226-6290
Practice Address - Fax:580-223-4381
Is Sole Proprietor?:No
Enumeration Date:2006-10-14
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5248122300000X, 1223P0221X
CO7780122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100182220CMedicaid
OK100091120AMedicaid
OK100091120BMedicaid