Provider Demographics
NPI:1558336271
Name:GARDNER, DONNA LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:LYNN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 S LAKEPORT ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51106-4516
Mailing Address - Country:US
Mailing Address - Phone:712-276-5547
Mailing Address - Fax:712-276-9099
Practice Address - Street 1:3500 S LAKEPORT ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51106-4516
Practice Address - Country:US
Practice Address - Phone:712-276-5547
Practice Address - Fax:712-276-9099
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA6866122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0206474Medicaid