=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992010219
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REDWOOD FAMILY DENTAL CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2010
-----------------------------------------------------
Last Update Date | 08/13/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1867 REDWOOD AVE SUITE 14
-----------------------------------------------------
City | GRANTS PASS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97527-6408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-474-2775
-----------------------------------------------------
Fax | 541-474-5005
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1867 REDWOOD AVE SUITE 14
-----------------------------------------------------
City | GRANTS PASS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97527-6408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-474-2775
-----------------------------------------------------
Fax | 541-474-5005
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. NATHAN MILO TANNER
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 360-989-0500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------