MEDICARE: TANNER GAMBLE DMD

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	390200000X	Student in an Organized Health Care Education/Training Program
2	1223G0001X	General Practice Dentistry	7842	NV

General Provider Information

NPI Number	:	1588369912
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TANNER GAMBLE DMD

Provider Business Mailing Address
First Line	:	7712 BANDON CLIFFS ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89084-4737
Country	:	US
Telephone Number	:	801-989-8687
Fax Number	:

Provider Business Practice Location Address
First Line	:	7712 BANDON CLIFFS ST
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89084-4737
Country	:	US
Telephone Number	:	801-989-8687
Fax Number	:

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

Provider Enumeration Date	:	04/04/2023
Last Update Date	:	07/03/2023

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