Provider Demographics
NPI:1538507322
Name:GARDNER, MICHAEL (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 E 1ST ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-6385
Mailing Address - Country:US
Mailing Address - Phone:714-617-5048
Mailing Address - Fax:714-617-5041
Practice Address - Street 1:1617 E 1ST ST
Practice Address - Street 2:SUITE A
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-6385
Practice Address - Country:US
Practice Address - Phone:714-617-5048
Practice Address - Fax:714-617-5041
Is Sole Proprietor?:No
Enumeration Date:2013-06-13
Last Update Date:2014-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA604851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice