Provider Demographics
NPI:1336364629
Name:GARDNER, DARREN WESLEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:DARREN
Middle Name:WESLEY
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 1:1675 N FREEDOM BLVD
Mailing Address - Street 2:STE 12A
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-2540
Mailing Address - Country:US
Mailing Address - Phone:801-374-8970
Mailing Address - Fax:
Practice Address - Street 1:1675 N FREEDOM BLVD
Practice Address - Street 2:STE 12A
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-2540
Practice Address - Country:US
Practice Address - Phone:801-374-8970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5937654-99231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice