Provider Demographics
NPI:1043908510
Name:GARDNER, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12483 PERSONS RD
Mailing Address - Street 2:
Mailing Address - City:BOW
Mailing Address - State:WA
Mailing Address - Zip Code:98232-7202
Mailing Address - Country:US
Mailing Address - Phone:360-391-7455
Mailing Address - Fax:
Practice Address - Street 1:111 SE EVERETT MALL WAY BLDG D
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-3208
Practice Address - Country:US
Practice Address - Phone:425-667-3333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-24
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADENT.DE.61435584122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist