Healthcare Provider Details

I. General information

NPI: 1134148935
Provider Name (Legal Business Name): STEPHEN TANNER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 05/18/2020
Certification Date: 05/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 SAINT MICHAELS DR STE C
SANTA FE NM
87505-7674
US

IV. Provider business mailing address

235 HARKINS LN
SANTA FE NM
87501-2214
US

V. Phone/Fax

Practice location:
  • Phone: 505-670-6145
  • Fax:
Mailing address:
  • Phone: 925-788-6522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number35557
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDD2457
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: