Provider Demographics
NPI:1053381061
Name:TAHARA, MARTIN A (DMD, MD)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:A
Last Name:TAHARA
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 CURVE CREST BLVD W
Mailing Address - Street 2:SUITE 108
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6044
Mailing Address - Country:US
Mailing Address - Phone:651-439-8030
Mailing Address - Fax:651-351-0821
Practice Address - Street 1:1701 CURVE CREST BLVD W
Practice Address - Street 2:SUITE 108
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082-6044
Practice Address - Country:US
Practice Address - Phone:651-439-8030
Practice Address - Fax:651-351-0821
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND114091223S0112X
WI5219-0151223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33761200Medicaid
WI33761200Medicaid