Provider Demographics
NPI:1780992784
Name:TANNER, NICHOLAS ALEXANDER (DDS)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:ALEXANDER
Last Name:TANNER
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 1:509 OLIVE WAY STE 1024
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1710
Mailing Address - Country:US
Mailing Address - Phone:206-623-7296
Mailing Address - Fax:206-623-7227
Practice Address - Street 1:509 OLIVE WAY STE 1024
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101
Practice Address - Country:US
Practice Address - Phone:206-623-7296
Practice Address - Fax:206-623-7227
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-24
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011538A122300000X
WADE60271600122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist