Provider Demographics
NPI:1669101200
Name:GODFREY, TANNER COLE (DMD)
Entity type:Individual
Prefix:
First Name:TANNER
Middle Name:COLE
Last Name:GODFREY
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 1:3000 LISA LN
Mailing Address - Street 2:
Mailing Address - City:FULTONDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35068-1025
Mailing Address - Country:US
Mailing Address - Phone:435-760-3457
Mailing Address - Fax:
Practice Address - Street 1:736 S 2000 W STE 2
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:UT
Practice Address - Zip Code:84075-9692
Practice Address - Country:US
Practice Address - Phone:801-614-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-08
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID25712471223X0400X
UT12890244-99221223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics