Provider Demographics
NPI:1982819348
Name:TANNER, STAFFORD DALE (DMD PA)
Entity Type:Individual
Prefix:DR
First Name:STAFFORD
Middle Name:DALE
Last Name:TANNER
Suffix:
Gender:M
Credentials:DMD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1065 JOHNNIE DODDS BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-6153
Mailing Address - Country:US
Mailing Address - Phone:843-884-5166
Mailing Address - Fax:843-849-0791
Practice Address - Street 1:1065 JOHNNIE DODDS BLVD STE A
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-6153
Practice Address - Country:US
Practice Address - Phone:843-884-5166
Practice Address - Fax:843-849-0791
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC26011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice