Provider Demographics
NPI:1730721499
Name:MITCHELL, TANNER JAMESON (DDS)
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:JAMESON
Last Name:MITCHELL
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 1:3105 MIDDLE DR STE A
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47203-4472
Mailing Address - Country:US
Mailing Address - Phone:317-656-0709
Mailing Address - Fax:812-379-1977
Practice Address - Street 1:3105 MIDDLE DR STE A
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-4472
Practice Address - Country:US
Practice Address - Phone:317-656-0709
Practice Address - Fax:812-379-1977
Is Sole Proprietor?:No
Enumeration Date:2019-10-15
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013213A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice