=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447460373
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHLEEN TANTUCO D.M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/22/2007
-----------------------------------------------------
Last Update Date | 04/21/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6667 VERNON WOODS DR SUITE A-19
-----------------------------------------------------
City | SANDY SPRINGS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30328-3215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-843-8431
-----------------------------------------------------
Fax | 404-843-8420
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6667 VERNON WOODS DR SUITE A-19
-----------------------------------------------------
City | SANDY SPRINGS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30328-3215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-843-8431
-----------------------------------------------------
Fax | 404-843-8420
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DSO35761
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DN014554
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------