Provider Demographics
NPI:1033111513
Name:MCKENNA, TANNER J (DDS)
Entity Type:Individual
Prefix:DR
First Name:TANNER
Middle Name:J
Last Name:MCKENNA
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 1:1410 NORTHPORT DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-2041
Mailing Address - Country:US
Mailing Address - Phone:608-244-3410
Mailing Address - Fax:608-244-1915
Practice Address - Street 1:1410 NORTHPORT DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53704-2041
Practice Address - Country:US
Practice Address - Phone:608-244-3410
Practice Address - Fax:608-244-1915
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5691-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice