Provider Demographics
NPI:1194335539
Name:TATUM, DELTON TODD (DDS)
Entity type:Individual
Prefix:
First Name:DELTON
Middle Name:TODD
Last Name:TATUM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2815 S GEORGIA ST
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79109-1975
Mailing Address - Country:US
Mailing Address - Phone:806-358-7646
Mailing Address - Fax:
Practice Address - Street 1:2815 S GEORGIA ST
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79109-1975
Practice Address - Country:US
Practice Address - Phone:806-358-7646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-31
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36455122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist