Provider Demographics
NPI:1841783651
Name:MARJAN, TAMARA (DMD)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:MARJAN
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 1:340 E RANDOLPH ST UNIT 205
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7418
Mailing Address - Country:US
Mailing Address - Phone:936-239-0753
Mailing Address - Fax:
Practice Address - Street 1:15909 HARLEM AVE
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-1609
Practice Address - Country:US
Practice Address - Phone:708-429-0915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.031700122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist