Healthcare Provider Details

I. General information

NPI: 1003669862
Provider Name (Legal Business Name): BRYCE TANNER GARDNER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2024
Last Update Date: 04/10/2024
Certification Date: 04/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

218 E 800 S
OREM UT
84058-5008
US

IV. Provider business mailing address

417 MILLCREEK RD
PLEASANT GROVE UT
84062-8814
US

V. Phone/Fax

Practice location:
  • Phone: 520-850-5708
  • Fax:
Mailing address:
  • Phone: 520-850-5708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number13899356-9926
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: