Provider Demographics
NPI:1912140385
Name:TAVENNER, DUSTIN GAYLE (DC)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:GAYLE
Last Name:TAVENNER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:213 N STETSON AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-7803
Mailing Address - Country:US
Mailing Address - Phone:312-552-3000
Mailing Address - Fax:312-552-3001
Practice Address - Street 1:213 N STETSON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-7803
Practice Address - Country:US
Practice Address - Phone:312-552-3000
Practice Address - Fax:312-552-3001
Is Sole Proprietor?:No
Enumeration Date:2009-04-14
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038011196111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor