Provider Demographics
NPI:1861721938
Name:GARDNER, DAVID (DMD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1714 LOCUST ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-6153
Mailing Address - Country:US
Mailing Address - Phone:215-732-2490
Mailing Address - Fax:215-732-2490
Practice Address - Street 1:1714 LOCUST ST
Practice Address - Street 2:SUITE 2
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19103-6153
Practice Address - Country:US
Practice Address - Phone:215-732-2490
Practice Address - Fax:215-732-2490
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-18
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS037861122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist