Healthcare Provider Details

I. General information

NPI: 1225618796
Provider Name (Legal Business Name): TANNER BROWN DMD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2021
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 MIRALAGO SHORE DR
SAINT PETERS MO
63376-3189
US

IV. Provider business mailing address

760 NAPA LN
SAINT CHARLES MO
63304-1458
US

V. Phone/Fax

Practice location:
  • Phone: 636-928-4090
  • Fax:
Mailing address:
  • Phone: 618-791-7667
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. TANNER MICHAEL BROWN
Title or Position: DENTIST
Credential: DMD
Phone: 618-791-7666