Provider Demographics
NPI:1366451403
Name:GARDNER, JESS A (DMD, MD)
Entity Type:Individual
Prefix:DR
First Name:JESS
Middle Name:A
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:745 OLD NORCROSS RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-4317
Mailing Address - Country:US
Mailing Address - Phone:770-962-9515
Mailing Address - Fax:770-962-2722
Practice Address - Street 1:745 OLD NORCROSS RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-4317
Practice Address - Country:US
Practice Address - Phone:770-962-9515
Practice Address - Fax:770-962-2722
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADNGA0001981223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAI21786Medicare UPIN
GA85BBBDHMedicare ID - Type UnspecifiedPROVIDER NUMBER