MEDICARE: DR. PAUL J TIERNAN 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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	DA035787	CA

General Provider Information

NPI Number	:	1942309877
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PAUL J TIERNAN DDS

Provider Business Mailing Address
First Line	:	30 DOCTORS PARK DR
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-6615
Country	:	US
Telephone Number	:	707-546-4727
Fax Number	:	707-546-3123

Provider Business Practice Location Address
First Line	:	30 DOCTORS PARK DR
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95405-6615
Country	:	US
Telephone Number	:	707-546-4727
Fax Number	:	707-546-3123

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

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	07/08/2007

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