1164688453 NPI number — TARA LYNNE DEAN

Table of content: TARA LYNNE DEAN (NPI 1164688453)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164688453 NPI number — TARA LYNNE DEAN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEAN
Provider First Name:
TARA
Provider Middle Name:
LYNNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164688453
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
534 N. ELM ST.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DENTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76201-4114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
940-566-5714
Provider Business Mailing Address Fax Number:
940-381-0157

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
534 N ELM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DENTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76201-4114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
940-566-5714
Provider Business Practice Location Address Fax Number:
940-381-0157
Provider Enumeration Date:
08/06/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  1182473 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00935327 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 854T73 . This is a "BC/BS TX - EFFECT 02/01/2011" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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