Provider Demographics
NPI:1093490120
Name:GARDNER, JORDAN LOUISE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:LOUISE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 22ND AVE S APT 1
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3131
Mailing Address - Country:US
Mailing Address - Phone:507-676-5675
Mailing Address - Fax:
Practice Address - Street 1:10700 FRANCE AVE S STE 102
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55431-3693
Practice Address - Country:US
Practice Address - Phone:952-679-3531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-16
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND148991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice