Provider Demographics
NPI:1447460373
Name:TANTUCO, KATHLEEN (DMD)
Entity type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:
Last Name:TANTUCO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6667 VERNON WOODS DR
Mailing Address - Street 2:SUITE A-19
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30328-3215
Mailing Address - Country:US
Mailing Address - Phone:404-843-8431
Mailing Address - Fax:404-843-8420
Practice Address - Street 1:6667 VERNON WOODS DR
Practice Address - Street 2:SUITE A-19
Practice Address - City:SANDY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30328-3215
Practice Address - Country:US
Practice Address - Phone:404-843-8431
Practice Address - Fax:404-843-8420
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADSO35761122300000X
GADN0145541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist