Provider Demographics
NPI:1053099556
Name:FARIS, TAMARA
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
Last Name:FARIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18W070 ROYCE BLVD APT 254
Mailing Address - Street 2:
Mailing Address - City:OAKBROOK TERRACE
Mailing Address - State:IL
Mailing Address - Zip Code:60181-4888
Mailing Address - Country:US
Mailing Address - Phone:414-334-4063
Mailing Address - Fax:
Practice Address - Street 1:5307 W 79TH ST
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:IL
Practice Address - Zip Code:60459-1403
Practice Address - Country:US
Practice Address - Phone:708-424-5650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019034482122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist