=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962225425
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMIL TANASE DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/04/2024
-----------------------------------------------------
Last Update Date | 11/04/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 525 S FAIRMONT AVE STE H
-----------------------------------------------------
City | LODI
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95240-3860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-369-2696
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 525 S FAIRMONT AVE STE H
-----------------------------------------------------
City | LODI
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95240-3860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-369-2696
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/OWNER
-----------------------------------------------------
Name | DR. EMIL TANASE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 209-369-2696
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------