MEDICARE: TANNER LAYNE CRANDALL DDS

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	122300000X	Dentist	12013136A	IN

General Provider Information

NPI Number	:	1730746710
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TANNER LAYNE CRANDALL DDS

Provider Business Mailing Address
First Line	:	3840 CHURCHMAN WOODS BLVD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46203-6094
Country	:	US
Telephone Number	:	260-515-3217
Fax Number	:

Provider Business Practice Location Address
First Line	:	7625 S MERIDIAN ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46217-4257
Country	:	US
Telephone Number	:	317-881-8271
Fax Number	:

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

Provider Enumeration Date	:	05/24/2019
Last Update Date	:	05/24/2019

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