MEDICARE: DR. TANNER DOUGLAS BENNION DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry	DEN-DEN-LIC-5951	MT

General Provider Information

NPI Number	:	1346631249
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TANNER DOUGLAS BENNION DDS

Provider Business Mailing Address
First Line	:	6238 SW 85TH ST
Second Line	:
City	:	GAINESVILLE
State	:	FL
Zip	:	32608-8512
Country	:	US
Telephone Number	:	801-368-9811
Fax Number	:

Provider Business Practice Location Address
First Line	:	2700 GRAND AVE STE B
Second Line	:
City	:	BILLINGS
State	:	MT
Zip	:	59102-2682
Country	:	US
Telephone Number	:	801-368-9811
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/12/2015
Last Update Date	:	02/12/2015

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