Healthcare Provider Details

I. General information

NPI: 1861575672
Provider Name (Legal Business Name): TARA JEFFERSON DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 FRANKFORT ST
BROOKSVILLE KY
41004
US

IV. Provider business mailing address

224 FRANKFORT STREET
BROOKSVILLE KY
41004
US

V. Phone/Fax

Practice location:
  • Phone: 606-735-3114
  • Fax: 606-735-3114
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7850
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: