Provider Demographics
NPI:1992474688
Name:TANNER, KELLY G (RDH)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:G
Last Name:TANNER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 MARYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23185-3274
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:169 MARYWOOD DR
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-3274
Practice Address - Country:US
Practice Address - Phone:804-536-3022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0402004299124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist