Provider Demographics
NPI:1326114067
Name:GARDNER, DAVID MICHAEL (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MICHAEL
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 MINEOLA AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:ROSLYN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577
Mailing Address - Country:US
Mailing Address - Phone:516-484-6394
Mailing Address - Fax:
Practice Address - Street 1:125 MINEOLA AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:ROSLYN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11577
Practice Address - Country:US
Practice Address - Phone:516-484-6394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY048683-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist