Healthcare Provider Details

I. General information

NPI: 1275940686
Provider Name (Legal Business Name): TARHONDA LEAH INGRAM DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2014
Last Update Date: 11/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 VILSECK ROAD, BLDG. 419-2
FT. STEWART GA
31315
US

IV. Provider business mailing address

1061 HARMON AVE US ARMY DENTAL HEALTH ACTIVITY
FORT STEWART GA
31314-5641
US

V. Phone/Fax

Practice location:
  • Phone: 912-257-7056
  • Fax: 912-257-7055
Mailing address:
  • Phone: 912-435-7006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN014799
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: