Provider Demographics
NPI:1932685740
Name:BRANTLEY, TARA POWERS (MD)
Entity type:Individual
Prefix:DR
First Name:TARA
Middle Name:POWERS
Last Name:BRANTLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TARA
Other - Middle Name:
Other - Last Name:POWERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:707 PARNASSUS AVE # D1201
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-2210
Mailing Address - Country:US
Mailing Address - Phone:415-476-8220
Mailing Address - Fax:
Practice Address - Street 1:707 PARNASSUS AVE # D1201
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2210
Practice Address - Country:US
Practice Address - Phone:415-476-8220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-15
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA182566208600000X, 1223S0112X, 208600000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery