Provider Demographics
NPI:1639521404
Name:KHAMO, TARA (DDS)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:
Last Name:KHAMO
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 1:4071 LEE RD STE 260
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-2173
Mailing Address - Country:US
Mailing Address - Phone:216-861-6200
Mailing Address - Fax:216-363-7490
Practice Address - Street 1:4071 LEE RD STE 260
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-2173
Practice Address - Country:US
Practice Address - Phone:216-861-6200
Practice Address - Fax:216-363-7490
Is Sole Proprietor?:No
Enumeration Date:2016-07-06
Last Update Date:2019-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRES.0041341223G0001X
CA100221122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice