Healthcare Provider Details

I. General information

NPI: 1750010237
Provider Name (Legal Business Name): TANNER WELBY DICE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2022
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3840 ED DR STE 120
RALEIGH NC
27612-8097
US

IV. Provider business mailing address

3840 ED DR STE 120
RALEIGH NC
27612-8097
US

V. Phone/Fax

Practice location:
  • Phone: 859-432-0047
  • Fax:
Mailing address:
  • Phone: 859-432-0047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number38422
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number28479
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number14649
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: