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General NPI Number Information
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NPI Number | 1346648656
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Entity Type | Organization
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Legal Business Name | TANNER FAMILY DENTISTRY, DEVIN K. TANNER DDS, LLC
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Dates
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Enumeration Date | 12/18/2014
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Last Update Date | 01/26/2015
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Provider Practice Location Address
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Address Line | 220 SHOSHONE AVE
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City | GREEN RIVER
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State | WY
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Zip | 82935-5468
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Country | US
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Telephone | 307-875-7770
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 127
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City | GREEN RIVER
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State | WY
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Zip | 82935-0127
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Country | US
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Telephone | 307-875-7770
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. DEVIN K TANNER
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Credential | DDS
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Telephone | 208-716-4382
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 1382
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License Number State | WY
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