=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255773305
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERT E TANNER D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/17/2013
-----------------------------------------------------
Last Update Date | 07/17/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22516 SE 64TH PL STE 120
-----------------------------------------------------
City | ISSAQUAH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98027-5379
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-392-8882
-----------------------------------------------------
Fax | 425-392-9101
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22516 SE 64TH PL STE 120
-----------------------------------------------------
City | ISSAQUAH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98027-5379
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 425-392-8882
-----------------------------------------------------
Fax | 425-392-9101
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 6439
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------