Provider Demographics
NPI:1346648656
Name:TANNER FAMILY DENTISTRY, DEVIN K. TANNER DDS, LLC
Entity type:Organization
Organization Name:TANNER FAMILY DENTISTRY, DEVIN K. TANNER DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEVIN
Authorized Official - Middle Name:K
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-716-4382
Mailing Address - Street 1:PO BOX 127
Mailing Address - Street 2:
Mailing Address - City:GREEN RIVER
Mailing Address - State:WY
Mailing Address - Zip Code:82935-0127
Mailing Address - Country:US
Mailing Address - Phone:307-875-7770
Mailing Address - Fax:
Practice Address - Street 1:220 SHOSHONE AVE
Practice Address - Street 2:
Practice Address - City:GREEN RIVER
Practice Address - State:WY
Practice Address - Zip Code:82935-5468
Practice Address - Country:US
Practice Address - Phone:307-875-7770
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-18
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY13821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty