Healthcare Provider Details

I. General information

NPI: 1972410603
Provider Name (Legal Business Name): TARA TAVAKOLIAN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2026
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5979 DESERT STORM AVE
FORT CAMPBELL KY
42223
US

IV. Provider business mailing address

1500 DALTON SMITH COURT 212
CLARKSVILLE TN
37043
US

V. Phone/Fax

Practice location:
  • Phone: 888-217-4563
  • Fax:
Mailing address:
  • Phone: 571-344-1223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number143039059926
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: