Provider Demographics
NPI:1851703458
Name:STREAM, TARA FERRIS (DDS)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:FERRIS
Last Name:STREAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:M
Other - Last Name:FERRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 959
Mailing Address - Street 2:
Mailing Address - City:SHEBOYGAN
Mailing Address - State:WI
Mailing Address - Zip Code:53082-0959
Mailing Address - Country:US
Mailing Address - Phone:920-783-6633
Mailing Address - Fax:920-783-6392
Practice Address - Street 1:601 BUFFALO ST
Practice Address - Street 2:
Practice Address - City:MANITOWOC
Practice Address - State:WI
Practice Address - Zip Code:54220-6817
Practice Address - Country:US
Practice Address - Phone:920-686-2333
Practice Address - Fax:920-783-6392
Is Sole Proprietor?:No
Enumeration Date:2014-05-30
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7234-15122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100037927Medicaid