Provider Demographics
NPI:1861412934
Name:TANNENBAUM, KENNETH (DDS)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:
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 1:1 WILMINGTON DR
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-4013
Mailing Address - Country:US
Mailing Address - Phone:631-643-5079
Mailing Address - Fax:
Practice Address - Street 1:1 WILMINGTON DR
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-4013
Practice Address - Country:US
Practice Address - Phone:631-643-5079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0389491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice