Provider Demographics
NPI:1457791253
Name:GARDNER LAPORTE, KELSEY (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:KELSEY
Middle Name:
Last Name:GARDNER LAPORTE
Suffix:
Gender:F
Credentials:DDS, MD
Other - Prefix:DR
Other - First Name:KELSEY
Other - Middle Name:
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS, MD
Mailing Address - Street 1:205 SOUTHDOWNE DR
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-3747
Mailing Address - Country:US
Mailing Address - Phone:865-381-8867
Mailing Address - Fax:865-724-1803
Practice Address - Street 1:205 SOUTHDOWNE DR
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801-3747
Practice Address - Country:US
Practice Address - Phone:865-381-8867
Practice Address - Fax:865-724-1803
Is Sole Proprietor?:No
Enumeration Date:2013-06-26
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7105204E00000X
TN11255204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery