Provider Demographics
NPI:1144364639
Name:GARDNER WADE D.D.S. LLC
Entity type:Organization
Organization Name:GARDNER WADE D.D.S. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:GARDNER
Authorized Official - Last Name:WADE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:917-657-5233
Mailing Address - Street 1:560 W 43RD ST
Mailing Address - Street 2:APT. 35C
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10036-4300
Mailing Address - Country:US
Mailing Address - Phone:917-657-5233
Mailing Address - Fax:
Practice Address - Street 1:9828 BLUEBONNET BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-6461
Practice Address - Country:US
Practice Address - Phone:225-752-3407
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA55271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty