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General NPI Number Information
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NPI Number | 1720504699
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Entity Type | Individual
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Provider Name | TANNER SONG DDS
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Gender | Male
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Dates
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Enumeration Date | 08/22/2017
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Last Update Date | 08/22/2017
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Provider Practice Location Address
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Address Line | 233 CAJON ST STE 3
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City | REDLANDS
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State | CA
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Zip | 92373-5239
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Country | US
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Telephone | 909-844-0497
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Fax |
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Provider Business Mailing Address
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Address Line | 363 SUMMIT AVE
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City | REDLANDS
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State | CA
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Zip | 92373-6853
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Country | US
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Telephone | 19098440497
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 101933
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License Number State | CA
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