Healthcare Provider Details

I. General information

NPI: 1669722856
Provider Name (Legal Business Name): RICHARD IAIN TANN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2012
Last Update Date: 09/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 W ALEXANDRINE ST FL 3
DETROIT MI
48201-2015
US

IV. Provider business mailing address

1479 POPE STREET
LASALLE ONTARIO
N9J3R8
CA

V. Phone/Fax

Practice location:
  • Phone: 313-576-2551
  • Fax: 313-576-2556
Mailing address:
  • Phone: 519-819-2555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number290102739
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: