Provider Demographics
NPI:1609879188
Name:GARDNER, KIM L (DDS)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:L
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 1:13346 RAVENNA RD
Mailing Address - Street 2:STE 5
Mailing Address - City:CHARDON
Mailing Address - State:OH
Mailing Address - Zip Code:44024-7030
Mailing Address - Country:US
Mailing Address - Phone:440-286-9531
Mailing Address - Fax:
Practice Address - Street 1:13346 RAVENNA RD
Practice Address - Street 2:STE 5
Practice Address - City:CHARDON
Practice Address - State:OH
Practice Address - Zip Code:44024-7030
Practice Address - Country:US
Practice Address - Phone:440-286-9531
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH16747122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist