Healthcare Provider Details

I. General information

NPI: 1336368240
Provider Name (Legal Business Name): MARCUS BRIAN TANABE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 10/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1165 S COLUMBIA RD STE C
GRAND FORKS ND
58201-4007
US

IV. Provider business mailing address

1165 S COLUMBIA RD STE C
GRAND FORKS ND
58201-4007
US

V. Phone/Fax

Practice location:
  • Phone: 701-772-7379
  • Fax: 701-772-9643
Mailing address:
  • Phone: 701-772-7379
  • Fax: 701-772-9643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number1950
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: