Provider Demographics
NPI:1598927253
Name:GARDNER, HARRELL LEE JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:HARRELL
Middle Name:LEE
Last Name:GARDNER
Suffix:JR
Gender:M
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:PO BOX 969
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29551-0969
Mailing Address - Country:US
Mailing Address - Phone:843-383-4562
Mailing Address - Fax:843-332-9701
Practice Address - Street 1:935 W HOME AVE
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-4435
Practice Address - Country:US
Practice Address - Phone:843-383-4562
Practice Address - Fax:843-332-9701
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1800122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ18008Medicaid