MEDICARE: TANNER GUSTAFSON

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	122300000X	Dentist	DN122359	GA
2	1223G0001X	General Practice Dentistry	10270	SC

General Provider Information

NPI Number	:	1669049821
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TANNER GUSTAFSON

Provider Business Mailing Address
First Line	:	1137 SALEM BAY DR
Second Line	:
City	:	BEAUFORT
State	:	SC
Zip	:	29902-5252
Country	:	US
Telephone Number	:	320-815-1163
Fax Number	:

Provider Business Practice Location Address
First Line	:	27A KEMMERLIN LN
Second Line	:
City	:	BEAUFORT
State	:	SC
Zip	:	29907-2702
Country	:	US
Telephone Number	:	843-522-2007
Fax Number	:

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

Provider Enumeration Date	:	06/07/2021
Last Update Date	:	05/03/2023

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Directions to “ TANNER GUSTAFSON ” Practice Location

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