Provider Demographics
NPI:1215167002
Name:TANTY, KEVIN (DDS)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:TANTY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:KEVIN
Other - Middle Name:THOMAS WILLIAM
Other - Last Name:TANTY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:15100 LIBRARY LN
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-5291
Mailing Address - Country:US
Mailing Address - Phone:262-641-0056
Mailing Address - Fax:
Practice Address - Street 1:15100 LIBRARY LN
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-5291
Practice Address - Country:US
Practice Address - Phone:262-641-0056
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-15
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI64341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice