Provider Demographics
NPI:1689991762
Name:CLELEN C. TANNER, DDS, INC
Entity Type:Organization
Organization Name:CLELEN C. TANNER, DDS, INC
Other - Org Name:FOOTHILL DENTAL
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLELEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:510-733-1455
Mailing Address - Street 1:21911 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94541-2118
Mailing Address - Country:US
Mailing Address - Phone:510-733-1455
Mailing Address - Fax:510-889-8395
Practice Address - Street 1:21911 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94541-2118
Practice Address - Country:US
Practice Address - Phone:510-733-1455
Practice Address - Fax:510-889-8395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-28
Last Update Date:2010-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA260031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1215080445OtherNPI
CADC0260031Medicare UPIN
CAU89763Medicare UPIN