Provider Demographics
NPI:1124406665
Name:TANNER, TYSON (DMD)
Entity Type:Individual
Prefix:
First Name:TYSON
Middle Name:
Last Name:TANNER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHARITON
Mailing Address - State:IA
Mailing Address - Zip Code:50049-1272
Mailing Address - Country:US
Mailing Address - Phone:641-774-2312
Mailing Address - Fax:
Practice Address - Street 1:117 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CHARITON
Practice Address - State:IA
Practice Address - Zip Code:50049-1272
Practice Address - Country:US
Practice Address - Phone:641-774-2312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-18
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA93771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice