Provider Demographics
NPI:1114187598
Name:SCOTT R GARDNER DDS PC
Entity Type:Organization
Organization Name:SCOTT R GARDNER DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DETIST
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-466-3239
Mailing Address - Street 1:2065 12TH AVE RD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6311
Mailing Address - Country:US
Mailing Address - Phone:208-466-3239
Mailing Address - Fax:
Practice Address - Street 1:2065 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6311
Practice Address - Country:US
Practice Address - Phone:208-466-3239
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3527122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806096200Medicaid