Provider Demographics
NPI:1841803657
Name:BLOCK, TANARA DAWN (RDH)
Entity Type:Individual
Prefix:
First Name:TANARA
Middle Name:DAWN
Last Name:BLOCK
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 STUART ST APT 8
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-2442
Mailing Address - Country:US
Mailing Address - Phone:970-270-0066
Mailing Address - Fax:
Practice Address - Street 1:1325 HOVER ST STE 201
Practice Address - Street 2:
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3176
Practice Address - Country:US
Practice Address - Phone:303-722-8020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-31
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO906209124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist