Provider Demographics
NPI:1356753578
Name:GARDNER, RESA J (DDS)
Entity type:Individual
Prefix:
First Name:RESA
Middle Name:J
Last Name:GARDNER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:RESA
Other - Middle Name:J
Other - Last Name:ESPINOZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:28960 US HIGHWAY 34
Mailing Address - Street 2:
Mailing Address - City:WRAY
Mailing Address - State:CO
Mailing Address - Zip Code:80758-9333
Mailing Address - Country:US
Mailing Address - Phone:719-588-3036
Mailing Address - Fax:
Practice Address - Street 1:416 MAIN ST
Practice Address - Street 2:
Practice Address - City:WRAY
Practice Address - State:CO
Practice Address - Zip Code:80758-1725
Practice Address - Country:US
Practice Address - Phone:970-332-4817
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-22
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002022091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice