Provider Demographics
NPI:1508153735
Name:GARDNER, SHANNON K (DMD)
Entity Type:Individual
Prefix:DR
First Name:SHANNON
Middle Name:K
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 1:1058 N TAMIAMI TRL STE 106
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34236-2427
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1058 N TAMIAMI TRL STE 106
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34236-2427
Practice Address - Country:US
Practice Address - Phone:941-444-6640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-08
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN258741223G0001X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No101Y00000XBehavioral Health & Social Service ProvidersCounselor