Provider Demographics
NPI:1588222632
Name:BROWN, TANNER MICHAEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:TANNER
Middle Name:MICHAEL
Last Name:BROWN
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 1:6065 MID RIVERS MALL DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63304-1108
Mailing Address - Country:US
Mailing Address - Phone:618-791-7666
Mailing Address - Fax:
Practice Address - Street 1:6065 MID RIVERS MALL DR
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63304-1108
Practice Address - Country:US
Practice Address - Phone:636-928-4090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0321461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No1223G0001XDental ProvidersDentistGeneral Practice