Provider Demographics
NPI:1851634265
Name:JON D TANNER, DDS, PC
Entity Type:Organization
Organization Name:JON D TANNER, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:D
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:907-456-5665
Mailing Address - Street 1:1305 21ST AVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-6084
Mailing Address - Country:US
Mailing Address - Phone:907-456-5665
Mailing Address - Fax:907-456-1753
Practice Address - Street 1:1305 21ST AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-6084
Practice Address - Country:US
Practice Address - Phone:907-456-5665
Practice Address - Fax:907-456-1753
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-03
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKD 868122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD9416Medicaid
AK834977OtherUNITED CONCORDIA