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General NPI Number Information
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NPI Number | 1720623606
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Entity Type | Individual
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Provider Name | JONATHAN COREY TANNER
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Gender | Male
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Dates
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Enumeration Date | 11/14/2019
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Last Update Date | 11/14/2019
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Provider Practice Location Address
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Address Line | 1344 22ND ST S
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City | ST PETERSBURG
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State | FL
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Zip | 33712-2744
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Country | US
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Telephone | 727-824-8181
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Fax |
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Provider Business Mailing Address
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Address Line | 7017 MONARCH PARK DR
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City | APOLLO BEACH
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State | FL
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Zip | 33572-8113
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Country | US
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Telephone | 614-961-9015
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | DN24535
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License Number State | FL
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