Provider Demographics
NPI:1316568652
Name:GARDNER, MARY STEPHANY (CRDH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:STEPHANY
Last Name:GARDNER
Suffix:
Gender:F
Credentials:CRDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 EBENEZER CHURCH RD APT 13
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22556-3881
Mailing Address - Country:US
Mailing Address - Phone:239-910-5553
Mailing Address - Fax:
Practice Address - Street 1:12351 DILLINGHAM SQ
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-5251
Practice Address - Country:US
Practice Address - Phone:239-910-5553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-28
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0402207699124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist