Provider Demographics
NPI:1326181579
Name:TANNER, NATHAN JOHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:JOHN
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:PO BOX 1190
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-1190
Mailing Address - Country:US
Mailing Address - Phone:307-733-2555
Mailing Address - Fax:307-733-2552
Practice Address - Street 1:200 E BROADWAY AVE # 1190
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8634
Practice Address - Country:US
Practice Address - Phone:307-733-5222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD7768122300000X
WY15381223G0001X
MT42001223G0001X
WYWY15381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY154182000Medicaid