Healthcare Provider Details

I. General information

NPI: 1326181579
Provider Name (Legal Business Name): NATHAN JOHN TANNER D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E BROADWAY AVE # 1190
JACKSON WY
83001-8634
US

IV. Provider business mailing address

PO BOX 1190
JACKSON WY
83001-1190
US

V. Phone/Fax

Practice location:
  • Phone: 307-733-5222
  • Fax:
Mailing address:
  • Phone: 307-733-2555
  • Fax: 307-733-2552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD7768
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1538
License Number StateWY
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4200
License Number StateMT
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberWY1538
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: