Provider Demographics
NPI:1710953765
Name:HACKNEY, TARA T (DMD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:T
Last Name:HACKNEY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:480 W LOWDER ST
Mailing Address - Street 2:
Mailing Address - City:MACCLENNY
Mailing Address - State:FL
Mailing Address - Zip Code:32063-2664
Mailing Address - Country:US
Mailing Address - Phone:904-259-6291
Mailing Address - Fax:904-259-4761
Practice Address - Street 1:480 W LOWDER ST
Practice Address - Street 2:
Practice Address - City:MACCLENNY
Practice Address - State:FL
Practice Address - Zip Code:32063-2664
Practice Address - Country:US
Practice Address - Phone:904-259-6291
Practice Address - Fax:904-259-4761
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN118881223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL071984601Medicaid