Provider Demographics
NPI:1750010237
Name:DICE, TANNER WELBY (DMD)
Entity Type:Individual
Prefix:DR
First Name:TANNER
Middle Name:WELBY
Last Name:DICE
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 1:9915 SHINING WILLOW DR APT 110
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-3156
Mailing Address - Country:US
Mailing Address - Phone:859-432-0047
Mailing Address - Fax:
Practice Address - Street 1:1845 E SOUTHLAKE BLVD # 144
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6501
Practice Address - Country:US
Practice Address - Phone:817-554-1122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX384221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty