Healthcare Provider Details

I. General information

NPI: 1316036171
Provider Name (Legal Business Name): TANNER WALLACE DMD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 09/17/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73 LYME RD SUITE 3
HANOVER NH
03755
US

IV. Provider business mailing address

73 LYME RD SUITE 3
HANOVER NH
03755
US

V. Phone/Fax

Practice location:
  • Phone: 603-643-3509
  • Fax: 603-643-3597
Mailing address:
  • Phone: 603-643-3509
  • Fax: 603-643-3597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2292
License Number StateNH

VIII. Authorized Official

Name: DR. TANNER WALLACE
Title or Position: PRESIDENT
Credential:
Phone: 603-643-3509