MEDICARE: KAYLA TAVARES, DDS, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics

General Provider Information

NPI Number	:	1811515182
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KAYLA TAVARES, DDS, PLLC

Provider Business Mailing Address
First Line	:	104 DIABLO DR
Second Line	:
City	:	BURLESON
State	:	TX
Zip	:	76028-6591
Country	:	US
Telephone Number	:	205-745-0942
Fax Number	:

Provider Business Practice Location Address
First Line	:	5540 SYCAMORE SCHOOL RD STE 336
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-3061
Country	:	US
Telephone Number	:	817-591-0336
Fax Number	:	817-591-0098

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KAYLA TAVARES
Credential	:	DDS, MDS
Telephone Number	:	205-745-0942

Provider Enumeration Date	:	07/13/2020
Last Update Date	:	07/13/2020

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