Provider Demographics
NPI:1730746710
Name:CRANDALL, TANNER LAYNE (DDS)
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:LAYNE
Last Name:CRANDALL
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 1:3840 CHURCHMAN WOODS BLVD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46203-6094
Mailing Address - Country:US
Mailing Address - Phone:260-515-3217
Mailing Address - Fax:
Practice Address - Street 1:7625 S MERIDIAN ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46217-4257
Practice Address - Country:US
Practice Address - Phone:317-881-8271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-24
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013136A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist