Provider Demographics
NPI:1992010219
Name:REDWOOD FAMILY DENTAL CARE
Entity Type:Organization
Organization Name:REDWOOD FAMILY DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:MILO
Authorized Official - Last Name:TANNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:360-989-0500
Mailing Address - Street 1:1867 REDWOOD AVE
Mailing Address - Street 2:SUITE 14
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97527-6408
Mailing Address - Country:US
Mailing Address - Phone:541-474-2775
Mailing Address - Fax:541-474-5005
Practice Address - Street 1:1867 REDWOOD AVE
Practice Address - Street 2:SUITE 14
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-6408
Practice Address - Country:US
Practice Address - Phone:541-474-2775
Practice Address - Fax:541-474-5005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-11
Last Update Date:2010-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty