Provider Demographics
NPI:1538619515
Name:GARDNER DENTAL LLC
Entity type:Organization
Organization Name:GARDNER DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:JACOB
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:614-254-3384
Mailing Address - Street 1:321 W SECOND ST
Mailing Address - Street 2:
Mailing Address - City:WINSLOW
Mailing Address - State:AZ
Mailing Address - Zip Code:86047-3406
Mailing Address - Country:US
Mailing Address - Phone:928-289-4441
Mailing Address - Fax:
Practice Address - Street 1:321 W SECOND ST
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:AZ
Practice Address - Zip Code:86047-3406
Practice Address - Country:US
Practice Address - Phone:928-289-4441
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-13
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD09050261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental