Provider Demographics
NPI: | 1497866735 |
---|---|
Name: | GARDNER & GARDNER DMD PC |
Entity Type: | Organization |
Organization Name: | GARDNER & GARDNER DMD PC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | JAMES |
Authorized Official - Middle Name: | STEVEN |
Authorized Official - Last Name: | GARDNER |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DMD |
Authorized Official - Phone: | 256-533-1435 |
Mailing Address - Street 1: | 107 MARSHEUTZ AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | HUNTSVILLE |
Mailing Address - State: | AL |
Mailing Address - Zip Code: | 35801 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 256-533-1435 |
Mailing Address - Fax: | 256-534-0779 |
Practice Address - Street 1: | 107 MARSHEUTZ AVE |
Practice Address - Street 2: | |
Practice Address - City: | HUNTSVILLE |
Practice Address - State: | AL |
Practice Address - Zip Code: | 35801 |
Practice Address - Country: | US |
Practice Address - Phone: | 256-533-1435 |
Practice Address - Fax: | 256-534-0779 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-08-31 |
Last Update Date: | 2020-08-22 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
AL | 4480 | 122300000X |
AL | 4510 | 122300000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 122300000X | Dental Providers | Dentist | Group - Single Specialty |