Provider Demographics
NPI:1124395389
Name:CHAD M GARDNER DDS A PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:CHAD M GARDNER DDS A PROFESSIONAL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:318-281-5972
Mailing Address - Street 1:625 S WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-5034
Mailing Address - Country:US
Mailing Address - Phone:318-281-5972
Mailing Address - Fax:318-281-9964
Practice Address - Street 1:625 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-5034
Practice Address - Country:US
Practice Address - Phone:318-281-5972
Practice Address - Fax:318-281-9964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5638122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1856380Medicaid