Provider Demographics
NPI:1699334656
Name:WILLOUGHBY, TARA LAYNE (DDS)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:LAYNE
Last Name:WILLOUGHBY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:HUMBLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:421 SW BETHANY DR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-2136
Mailing Address - Country:US
Mailing Address - Phone:723-400-8087
Mailing Address - Fax:
Practice Address - Street 1:421 SW BETHANY DR
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2136
Practice Address - Country:US
Practice Address - Phone:772-340-0805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-12
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN24652122300000X
MO2019019153122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist