Provider Demographics
NPI:1316930738
Name:KONRAD, TARAS JOSAPHAT (DMD)
Entity type:Individual
Prefix:DR
First Name:TARAS
Middle Name:JOSAPHAT
Last Name:KONRAD
Suffix:
Gender:M
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:NMRTC PENDLETON
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92055
Mailing Address - Country:US
Mailing Address - Phone:760-719-4747
Mailing Address - Fax:
Practice Address - Street 1:MCAGCTC , 23RD DENTAL
Practice Address - Street 2:BLDG 1591
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92278
Practice Address - Country:US
Practice Address - Phone:760-830-7054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS031194L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist