Provider Demographics
NPI:1528015468
Name:TANNEBRING, CHARLES JEFFREY (DMD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:JEFFREY
Last Name:TANNEBRING
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 1:22 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BEVERLY
Mailing Address - State:MA
Mailing Address - Zip Code:01915-4435
Mailing Address - Country:US
Mailing Address - Phone:978-922-0105
Mailing Address - Fax:
Practice Address - Street 1:22 BROADWAY
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-4435
Practice Address - Country:US
Practice Address - Phone:978-922-0105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA0137101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice