Provider Demographics
NPI:1720252224
Name:TANNENBAUM, CHARLES J (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:J
Last Name:TANNENBAUM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5404 W ELM ST
Mailing Address - Street 2:STE F
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-4052
Mailing Address - Country:US
Mailing Address - Phone:815-759-0871
Mailing Address - Fax:815-759-0875
Practice Address - Street 1:5404 W ELM ST
Practice Address - Street 2:STE F
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-4052
Practice Address - Country:US
Practice Address - Phone:815-759-0871
Practice Address - Fax:815-759-0875
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-15
Last Update Date:2012-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-015317122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist