Provider Demographics
NPI:1073804001
Name:GARDNER, THAYNE HENRIE (DDS)
Entity Type:Individual
Prefix:
First Name:THAYNE
Middle Name:HENRIE
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1268 W SOUTH JORDAN PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-4652
Mailing Address - Country:US
Mailing Address - Phone:801-446-8007
Mailing Address - Fax:801-676-1030
Practice Address - Street 1:1268 W SOUTH JORDAN PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-4652
Practice Address - Country:US
Practice Address - Phone:801-446-8007
Practice Address - Fax:801-676-1030
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-25
Last Update Date:2016-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4480-PD1223P0221X
UT92464741223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry