Provider Demographics
NPI:1003669862
Name:GARDNER, BRYCE TANNER (DMD)
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:TANNER
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 MILLCREEK RD
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-8814
Mailing Address - Country:US
Mailing Address - Phone:520-850-5708
Mailing Address - Fax:
Practice Address - Street 1:218 E 800 S
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-5008
Practice Address - Country:US
Practice Address - Phone:520-850-5708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13899356-9926122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist