Provider Demographics
NPI:1770224065
Name:MILLER JOHNSON, TARA KORTNEY
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:KORTNEY
Last Name:MILLER JOHNSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 GALA CT
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-5712
Mailing Address - Country:US
Mailing Address - Phone:818-272-9511
Mailing Address - Fax:
Practice Address - Street 1:134 BELVIDERE AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NJ
Practice Address - Zip Code:07882-1417
Practice Address - Country:US
Practice Address - Phone:908-835-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-02
Last Update Date:2025-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI02916400122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist