MEDICARE: DR. LAWRENCE TANNOR D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	36824	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	36824	OTHER	NY	LICENSE

General Provider Information

NPI Number	:	1528059524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAWRENCE TANNOR D.D.S.

Provider Business Mailing Address
First Line	:	2301 BRIGHAM ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-5511
Country	:	US
Telephone Number	:	718-646-6543
Fax Number	:	718-648-9386

Provider Business Practice Location Address
First Line	:	2301 BRIGHAM ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11229-5511
Country	:	US
Telephone Number	:	718-648-6543
Fax Number	:	718-648-9386

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2005
Last Update Date	:	07/08/2007

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