Provider Demographics
NPI:1538447685
Name:CULLY, TARA LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:TARA
Middle Name:LEE
Last Name:CULLY
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 1:114 UPPER BALCONES RD
Mailing Address - Street 2:
Mailing Address - City:BOERNE
Mailing Address - State:TX
Mailing Address - Zip Code:78006-8545
Mailing Address - Country:US
Mailing Address - Phone:830-446-5510
Mailing Address - Fax:
Practice Address - Street 1:5 COUGHRAN RD STE 302
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78006-8103
Practice Address - Country:US
Practice Address - Phone:830-446-5510
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-22
Last Update Date:2025-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX272631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX27263OtherLICENSE
TX126862508Medicaid