Provider Demographics
NPI:1659998730
Name:GARDNER, DOUGLAS SCOTT (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:SCOTT
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 1:3872 NEW BATTLE LN
Mailing Address - Street 2:
Mailing Address - City:BARGERSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46106-9610
Mailing Address - Country:US
Mailing Address - Phone:317-910-9546
Mailing Address - Fax:
Practice Address - Street 1:324 W 2ND ST
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-2199
Practice Address - Country:US
Practice Address - Phone:812-522-8608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-06
Last Update Date:2020-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013430A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice