Provider Demographics
NPI:1528418506
Name:GARDNER, CASEY (RDH)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:GARDNER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2441 21ST ST
Mailing Address - Street 2:
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-5582
Mailing Address - Country:US
Mailing Address - Phone:270-798-8751
Mailing Address - Fax:270-956-0266
Practice Address - Street 1:3603 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5803
Practice Address - Country:US
Practice Address - Phone:270-798-3544
Practice Address - Fax:270-956-0266
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-21
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4531124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist