Provider Demographics
NPI:1689410292
Name:SUTHERLAND, TARA (DDS)
Entity type:Individual
Prefix:DR
First Name:TARA
Middle Name:
Last Name:SUTHERLAND
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3119 N OAK STREET EXT
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-1008
Mailing Address - Country:US
Mailing Address - Phone:229-249-0717
Mailing Address - Fax:
Practice Address - Street 1:3119 N OAK STREET EXT
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-1008
Practice Address - Country:US
Practice Address - Phone:229-249-0717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-03
Last Update Date:2024-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN1234401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice