Provider Demographics
NPI:1891955050
Name:JOHN A GARDNER, DDS, PC
Entity Type:Organization
Organization Name:JOHN A GARDNER, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:573-443-2544
Mailing Address - Street 1:1316 OLD 63 S
Mailing Address - Street 2:STE. 201
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6092
Mailing Address - Country:US
Mailing Address - Phone:573-443-2544
Mailing Address - Fax:573-815-0840
Practice Address - Street 1:1316 OLD 63 S
Practice Address - Street 2:STE. 201
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-6092
Practice Address - Country:US
Practice Address - Phone:573-443-2544
Practice Address - Fax:573-815-0840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO109371223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty