Provider Demographics
NPI:1114509080
Name:GRAY, TANNER (DMD)
Entity Type:Individual
Prefix:
First Name:TANNER
Middle Name:
Last Name:GRAY
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 1:1650 E 3250 N
Mailing Address - Street 2:
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-1615
Mailing Address - Country:US
Mailing Address - Phone:435-770-9709
Mailing Address - Fax:
Practice Address - Street 1:BUILDING 20, SANTA FE DR
Practice Address - Street 2:
Practice Address - City:HOLLOMAN AFB
Practice Address - State:NM
Practice Address - Zip Code:88330
Practice Address - Country:US
Practice Address - Phone:575-572-8099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12322243-89031223G0001X
UT12322243-99221223G0001X
UT390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT177036536OtherDRIVERS LICENSE