Provider Demographics
NPI:1013574870
Name:PERRY, TANNER GARDNER (DMD)
Entity Type:Individual
Prefix:DR
First Name:TANNER
Middle Name:GARDNER
Last Name:PERRY
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 1:320 RIVER PARK DR STE 225
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-6065
Mailing Address - Country:US
Mailing Address - Phone:801-225-7111
Mailing Address - Fax:
Practice Address - Street 1:320 RIVER PARK DR STE 225
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-6065
Practice Address - Country:US
Practice Address - Phone:801-225-7111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-28
Last Update Date:2019-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11256978-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice