Provider Demographics
NPI:1891720280
Name:GARDNER, NICHOLAS FRANDY (DDS)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:FRANDY
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 1:119 E MAIN ST
Mailing Address - Street 2:PO BOX 374
Mailing Address - City:GOUVERNEUR
Mailing Address - State:NY
Mailing Address - Zip Code:13642-1408
Mailing Address - Country:US
Mailing Address - Phone:315-287-7900
Mailing Address - Fax:315-287-4789
Practice Address - Street 1:119 E MAIN ST
Practice Address - Street 2:
Practice Address - City:GOUVERNEUR
Practice Address - State:NY
Practice Address - Zip Code:13642-1408
Practice Address - Country:US
Practice Address - Phone:315-287-7900
Practice Address - Fax:315-287-4789
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0522331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02682337Medicaid