Provider Demographics
NPI:1962923557
Name:KAVANAGH, TARYNE MARIE (DMD)
Entity type:Individual
Prefix:
First Name:TARYNE
Middle Name:MARIE
Last Name:KAVANAGH
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2313 WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-3878
Mailing Address - Country:US
Mailing Address - Phone:810-824-0337
Mailing Address - Fax:
Practice Address - Street 1:21635 RYAN RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-2788
Practice Address - Country:US
Practice Address - Phone:586-757-7540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-04
Last Update Date:2021-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010223761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice