Provider Demographics
NPI:1356548184
Name:SECRET, TARA LEIGH (DDS)
Entity type:Individual
Prefix:DR
First Name:TARA
Middle Name:LEIGH
Last Name:SECRET
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:741 MULBERRY AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-2651
Mailing Address - Country:US
Mailing Address - Phone:304-669-8999
Mailing Address - Fax:
Practice Address - Street 1:8220 UNIVERSITY EXECUTIVE DR
Practice Address - Street 2:SUITE 111
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262
Practice Address - Country:US
Practice Address - Phone:704-548-8563
Practice Address - Fax:704-510-2793
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3710122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist