Provider Demographics
NPI:1043452899
Name:POOL, TARA NICHOLE (DDS)
Entity type:Individual
Prefix:MRS
First Name:TARA
Middle Name:NICHOLE
Last Name:POOL
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 1:1640 CHARLES PL.
Mailing Address - Street 2:STE 101
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66502
Mailing Address - Country:US
Mailing Address - Phone:785-537-8484
Mailing Address - Fax:785-537-2281
Practice Address - Street 1:711 W 90TH TER
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64114-3548
Practice Address - Country:US
Practice Address - Phone:913-638-5768
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-25
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS60676122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist