Provider Demographics
NPI:1407208853
Name:TANAKA, TSUYOSHI
Entity Type:Individual
Prefix:DR
First Name:TSUYOSHI
Middle Name:
Last Name:TANAKA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1395 CENTER DR RM D10-6
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0434
Mailing Address - Country:US
Mailing Address - Phone:317-515-2372
Mailing Address - Fax:
Practice Address - Street 1:1395 CENTER DR RM D10-6
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-0434
Practice Address - Country:US
Practice Address - Phone:317-515-2372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-11
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDTP6901223P0300X
MADL12969122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist