Provider Demographics
NPI:1417385030
Name:TANNER, CHRISTINA
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:TANNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CALLAWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54603-1102
Mailing Address - Country:US
Mailing Address - Phone:608-385-3236
Mailing Address - Fax:
Practice Address - Street 1:500 CALLAWAY BLVD
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54603-1102
Practice Address - Country:US
Practice Address - Phone:608-385-3236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-16
Last Update Date:2013-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10621-016124Q00000X
MNH8585124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist