MEDICARE: DR. EDDIE GLENN TENNISON D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	14580	TX
2	1223P0221X	Pediatric Dentistry	14580	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023068038
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDDIE GLENN TENNISON D.D.S.

Provider Business Mailing Address
First Line	:	2021 N MAYS ST STE 1200
Second Line	:
City	:	ROUND ROCK
State	:	TX
Zip	:	78664-2170
Country	:	US
Telephone Number	:	512-244-1221
Fax Number	:	512-244-7773

Provider Business Practice Location Address
First Line	:	2117 N MAYS ST
Second Line	:
City	:	ROUND ROCK
State	:	TX
Zip	:	78664-2155
Country	:	US
Telephone Number	:	512-244-1221
Fax Number	:	512-244-7773

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	09/23/2024

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