Provider Demographics
NPI:1184356032
Name:DOHM, TARA RENE (DMD)
Entity type:Individual
Prefix:DR
First Name:TARA
Middle Name:RENE
Last Name:DOHM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MS
Other - First Name:TARA
Other - Middle Name:RENE
Other - Last Name:WISNIEWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3488 MAHONEY DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49696-9001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2600 LAFRANIER RD
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-4765
Practice Address - Country:US
Practice Address - Phone:866-878-6557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901601288122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist