Healthcare Provider Details

I. General information

NPI: 1356990477
Provider Name (Legal Business Name): TARA WRIGHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2019
Last Update Date: 10/28/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 W 8TH ST
COFFEYVILLE KS
67337-4109
US

IV. Provider business mailing address

PO BOX 1832
PITTSBURG KS
66762-1832
US

V. Phone/Fax

Practice location:
  • Phone: 620-251-4979
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: