Provider Demographics
NPI:1154094159
Name:TANNEN, DANIEL LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:LEE
Last Name:TANNEN
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 1:59 DG AF POSTGRADUATE DENTAL SCHOOL
Mailing Address - Street 2:2133 PEPPERRELL STREET, BUILDING 3352
Mailing Address - City:JBSA-LACKLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78236-5313
Mailing Address - Country:US
Mailing Address - Phone:210-292-6258
Mailing Address - Fax:210-292-2618
Practice Address - Street 1:1615 TRUEMPER ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78236-5511
Practice Address - Country:US
Practice Address - Phone:505-206-7130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-27
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37309122300000X
UT13427199-9921122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1543552158OtherDOD