Provider Demographics
NPI:1932317914
Name:BOLT-MCCALL, TARA MICHELLE (RDH)
Entity Type:Individual
Prefix:MRS
First Name:TARA
Middle Name:MICHELLE
Last Name:BOLT-MCCALL
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:637 SHADYWOOD LN
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-6110
Mailing Address - Country:US
Mailing Address - Phone:865-566-7340
Mailing Address - Fax:865-691-4291
Practice Address - Street 1:323 FOX RD
Practice Address - Street 2:SUITE 200
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37922-3383
Practice Address - Country:US
Practice Address - Phone:865-690-5231
Practice Address - Fax:865-691-4291
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5664124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist