Provider Demographics
NPI:1851685697
Name:JOHNSON, TARA NICOLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:NICOLE
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:TARA
Other - Middle Name:NICOLE
Other - Last Name:GAINEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:7810 FM 1960
Mailing Address - Street 2:UNIT 101
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77346
Mailing Address - Country:US
Mailing Address - Phone:281-852-1191
Mailing Address - Fax:
Practice Address - Street 1:7810 FM 1960
Practice Address - Street 2:UNIT 101
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77346
Practice Address - Country:US
Practice Address - Phone:281-852-1191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-08
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TX285361223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program