Provider Demographics
NPI:1821289984
Name:TANNER, NATHAN M (DMD)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:M
Last Name:TANNER
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 1:2288 WILLIAMS HWY
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527
Mailing Address - Country:US
Mailing Address - Phone:541-862-1848
Mailing Address - Fax:541-474-5005
Practice Address - Street 1:725 N 5TH ST STE 101
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97530
Practice Address - Country:US
Practice Address - Phone:541-862-1848
Practice Address - Fax:541-474-5005
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2016-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD89471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice