Provider Demographics
NPI:1790859916
Name:GARDNER, WILLIAM EARLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:EARLE
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:PO BOX 1059
Mailing Address - Street 2:
Mailing Address - City:ROLAND
Mailing Address - State:OK
Mailing Address - Zip Code:74954-1059
Mailing Address - Country:US
Mailing Address - Phone:918-427-0772
Mailing Address - Fax:
Practice Address - Street 1:109 N 17TH ST
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72901-3223
Practice Address - Country:US
Practice Address - Phone:479-782-6021
Practice Address - Fax:479-709-0161
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4720122300000X
AR3510122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR183537608Medicaid