Provider Demographics
NPI:1528323060
Name:TAVARES, KAYLA (DDS)
Entity type:Individual
Prefix:DR
First Name:KAYLA
Middle Name:
Last Name:TAVARES
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 1:104 DIABLO DR
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-6591
Mailing Address - Country:US
Mailing Address - Phone:205-745-0942
Mailing Address - Fax:
Practice Address - Street 1:5540 SYCAMORE SCHOOL RD STE 336
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76123-3061
Practice Address - Country:US
Practice Address - Phone:817-591-0336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX311421223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics