Provider Demographics
NPI:1043232499
Name:TANDY, ROBERT BLAKE (DDS, MS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:BLAKE
Last Name:TANDY
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1236 VISTA VERDE RD
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-7553
Mailing Address - Country:US
Mailing Address - Phone:707-972-1123
Mailing Address - Fax:707-468-0899
Practice Address - Street 1:1236 VISTA VERDE RD
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-7553
Practice Address - Country:US
Practice Address - Phone:707-972-1123
Practice Address - Fax:707-468-0899
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA200521223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA68-0482541OtherTIN