Provider Demographics
NPI:1295219947
Name:ODOM, TANNER DWAIN (DC)
Entity Type:Individual
Prefix:DR
First Name:TANNER
Middle Name:DWAIN
Last Name:ODOM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3433 W DALLAS ST APT 1131
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77019-3842
Mailing Address - Country:US
Mailing Address - Phone:903-312-2605
Mailing Address - Fax:
Practice Address - Street 1:2030 NORTH LOOP W STE 120
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77018-8126
Practice Address - Country:US
Practice Address - Phone:903-312-2605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX13914111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor