Provider Demographics
NPI:1588976807
Name:TOM, TAMARA (DDS)
Entity type:Individual
Prefix:DR
First Name:TAMARA
Middle Name:
Last Name:TOM
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 1:3601 S 6TH AVE
Mailing Address - Street 2:DENTAL SERVICE
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85723-0001
Mailing Address - Country:US
Mailing Address - Phone:323-376-4999
Mailing Address - Fax:
Practice Address - Street 1:3601 S 6TH AVE
Practice Address - Street 2:DENTAL SERVICE
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85723-0001
Practice Address - Country:US
Practice Address - Phone:323-376-4999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-02
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
CA599101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program