Provider Demographics
NPI:1629190723
Name:TANNER, DAVID ROSS (DC)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ROSS
Last Name:TANNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 SUNRISE WAY
Mailing Address - Street 2:
Mailing Address - City:TOWACO
Mailing Address - State:NJ
Mailing Address - Zip Code:07082-1547
Mailing Address - Country:US
Mailing Address - Phone:973-334-2664
Mailing Address - Fax:973-682-7742
Practice Address - Street 1:212 MAIN ST
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:NJ
Practice Address - Zip Code:07035-3700
Practice Address - Country:US
Practice Address - Phone:973-268-7723
Practice Address - Fax:973-628-7742
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMCC 00228900111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ22 24230010OtherHORIZON BC BS
NJ450168Medicare ID - Type Unspecified