Healthcare Provider Details

I. General information

NPI: 1033111513
Provider Name (Legal Business Name): TANNER J. MCKENNA D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/13/2005
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2630 IRONWOOD DR
SUN PRAIRIE WI
53590-8830
US

IV. Provider business mailing address

2630 IRONWOOD DR
SUN PRAIRIE WI
53590-8830
US

V. Phone/Fax

Practice location:
  • Phone: 608-837-7842
  • Fax: 608-318-8787
Mailing address:
  • Phone: 608-837-7842
  • Fax: 608-318-8787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5691-015
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: