Provider Demographics
NPI:1336368240
Name:TANABE, MARCUS BRIAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARCUS
Middle Name:BRIAN
Last Name:TANABE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1165 S COLUMBIA RD STE C
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4007
Mailing Address - Country:US
Mailing Address - Phone:701-772-7379
Mailing Address - Fax:701-772-9643
Practice Address - Street 1:1165 S COLUMBIA RD STE C
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4007
Practice Address - Country:US
Practice Address - Phone:701-772-7379
Practice Address - Fax:701-772-9643
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2013-10-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ND19501223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery