Provider Demographics
NPI:1801013255
Name:REARDON, GAYLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:GAYLE
Middle Name:
Last Name:REARDON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3305 SOUTH LINCOLN AVENUE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-5224
Mailing Address - Country:US
Mailing Address - Phone:605-336-8144
Mailing Address - Fax:605-335-3568
Practice Address - Street 1:3305 SOUTH LINCOLN AVENUE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-5224
Practice Address - Country:US
Practice Address - Phone:605-336-8144
Practice Address - Fax:605-335-3568
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDM5181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDD8755OtherMINNESOTA LIC #
SDM518OtherSOUTH DAKOTA LIC #