Provider Demographics
NPI:1487875431
Name:GRIFFIN, TARA M (DMD)
Entity type:Individual
Prefix:DR
First Name:TARA
Middle Name:M
Last Name:GRIFFIN
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 1:402 43RD ST W STE A
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209-2953
Mailing Address - Country:US
Mailing Address - Phone:941-757-4642
Mailing Address - Fax:941-896-3130
Practice Address - Street 1:402 43RD ST W STE A
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209-2953
Practice Address - Country:US
Practice Address - Phone:941-757-4642
Practice Address - Fax:941-896-3130
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190247331223G0001X
FLDN209481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1487875431OtherNPI