Provider Demographics
NPI:1609864610
Name:GARDNER, BRADLEY ALLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:ALLEN
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 1:2009 OLD COUNTY ROAD 34 PL
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-6608
Mailing Address - Country:US
Mailing Address - Phone:952-890-0453
Mailing Address - Fax:952-736-2978
Practice Address - Street 1:2009 OLD COUNTY ROAD 34 PL
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-6608
Practice Address - Country:US
Practice Address - Phone:952-890-0453
Practice Address - Fax:952-736-2978
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8900122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist