Healthcare Provider Details

I. General information

NPI: 1790445872
Provider Name (Legal Business Name): TANNER B. GREGORY, D.D.S.,P.L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/30/2021
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3302 64TH ST STE B
LUBBOCK TX
79413-5743
US

IV. Provider business mailing address

3302 64TH ST STE B
LUBBOCK TX
79413-5743
US

V. Phone/Fax

Practice location:
  • Phone: 806-792-4889
  • Fax:
Mailing address:
  • Phone: 806-792-4889
  • 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: KIM WIDEMAN
Title or Position: OFFICE MANAGER/BOOKKEEPER
Credential:
Phone: 806-792-4889