Provider Demographics
NPI:1154091668
Name:GARDNER, ALYSSA (RDH)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26800 SUMMERDALE DR BLDG 3
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-2233
Mailing Address - Country:US
Mailing Address - Phone:248-986-0881
Mailing Address - Fax:
Practice Address - Street 1:26800 SUMMERDALE DR BLDG 3
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-2233
Practice Address - Country:US
Practice Address - Phone:248-986-0881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2902018762124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI02231991Medicaid