Provider Demographics
NPI:1598913006
Name:TANVISHUT, KUMJOHN (DDS)
Entity Type:Individual
Prefix:
First Name:KUMJOHN
Middle Name:
Last Name:TANVISHUT
Suffix:
Gender:M
Credentials:DDS
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 2222
Mailing Address - Street 2:
Mailing Address - City:LILLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27546-2222
Mailing Address - Country:US
Mailing Address - Phone:910-893-1096
Mailing Address - Fax:910-814-1559
Practice Address - Street 1:5923 W FRIENDLY AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-3207
Practice Address - Country:US
Practice Address - Phone:336-632-0744
Practice Address - Fax:336-632-0754
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-09
Last Update Date:2008-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8689122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty