Provider Demographics
NPI:1982059143
Name:BROWN, TARA (DMD)
Entity Type:Individual
Prefix:DR
First Name:TARA
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8272 DREAM BOAT DR UNIT 104
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31909-2555
Mailing Address - Country:US
Mailing Address - Phone:404-931-3923
Mailing Address - Fax:
Practice Address - Street 1:51 GAY CONNECTOR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:GA
Practice Address - Zip Code:30222-3339
Practice Address - Country:US
Practice Address - Phone:706-672-0819
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-25
Last Update Date:2018-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GADN0152021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program