Healthcare Provider Details

I. General information

NPI: 1073866679
Provider Name (Legal Business Name): AUBRIE LEIGH TANNER R.D.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2012
Last Update Date: 10/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7933 BAYMEADOWS WAY STE 5
JACKSONVILLE FL
32256-7514
US

IV. Provider business mailing address

7933 BAYMEADOWS WAY STE 5
JACKSONVILLE FL
32256-7514
US

V. Phone/Fax

Practice location:
  • Phone: 904-731-2162
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH21985
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: