Provider Demographics
NPI:1215080445
Name:TANNER, CLELEN CLARENCE (DDS)
Entity type:Individual
Prefix:DR
First Name:CLELEN
Middle Name:CLARENCE
Last Name:TANNER
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 1:21911 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-2118
Mailing Address - Country:US
Mailing Address - Phone:510-733-1455
Mailing Address - Fax:510-889-8395
Practice Address - Street 1:21911 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-2118
Practice Address - Country:US
Practice Address - Phone:510-733-1455
Practice Address - Fax:510-889-8395
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA260031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice