Provider Demographics
NPI:1184704801
Name:GARDNER, JEFFREY JEROME (DMD, PA)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JEROME
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DMD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1077 JOHNNIE DODDS BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3155
Mailing Address - Country:US
Mailing Address - Phone:843-884-0335
Mailing Address - Fax:843-884-6399
Practice Address - Street 1:1077 JOHNNIE DODDS BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3155
Practice Address - Country:US
Practice Address - Phone:843-884-0335
Practice Address - Fax:843-884-6399
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC31631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice