Provider Demographics
NPI:1013926872
Name:GARDNER, JONATHAN BLAIR (DDS)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:BLAIR
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 930
Mailing Address - Street 2:
Mailing Address - City:EAST CARBON
Mailing Address - State:UT
Mailing Address - Zip Code:84520-0930
Mailing Address - Country:US
Mailing Address - Phone:435-888-4411
Mailing Address - Fax:435-888-4411
Practice Address - Street 1:331 HIGHWAY 123
Practice Address - Street 2:
Practice Address - City:EAST CARBON
Practice Address - State:UT
Practice Address - Zip Code:84520-0930
Practice Address - Country:US
Practice Address - Phone:435-888-4411
Practice Address - Fax:435-888-2270
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-07
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT326378-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice