Healthcare Provider Details

I. General information

NPI: 1386943777
Provider Name (Legal Business Name): JOSEPH HENRY DANNENBAUM IV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2011
Last Update Date: 05/06/2021
Certification Date: 04/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVE
TACOMA WA
98431-0001
US

IV. Provider business mailing address

9040 JACKSON AVE
TACOMA WA
98431-0001
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-1484
  • Fax:
Mailing address:
  • Phone: 253-968-1484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberTP814
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number26976
License Number StateNE
# 3
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number278065
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: