Healthcare Provider Details

I. General information

NPI: 1013836287
Provider Name (Legal Business Name): TANNER BOATMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1624 LIBRARY LN
MINDEN NV
89423-4488
US

IV. Provider business mailing address

1783 LANTANA DR
MINDEN NV
89423-5172
US

V. Phone/Fax

Practice location:
  • Phone: 916-580-5572
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number113088
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: