Provider Demographics
NPI:1770785891
Name:SMITH, TARA (RDH)
Entity type:Individual
Prefix:MS
First Name:TARA
Middle Name:
Last Name:SMITH
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 1:709 DAVOS POINTE G9
Mailing Address - Street 2:
Mailing Address - City:WOODRIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:12789
Mailing Address - Country:US
Mailing Address - Phone:845-239-9361
Mailing Address - Fax:
Practice Address - Street 1:400 STATE ROUTE 17M
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950
Practice Address - Country:US
Practice Address - Phone:845-782-0189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024682124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist