Provider Demographics
NPI:1396039293
Name:GARDNER, LYDIA (DMD)
Entity Type:Individual
Prefix:DR
First Name:LYDIA
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 JOHN ST
Mailing Address - Street 2:1608
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10038-2903
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:99 JOHN ST
Practice Address - Street 2:1608
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10038-2903
Practice Address - Country:US
Practice Address - Phone:443-306-6392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-08
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0385321223P0300X
NY0566401223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics