Provider Demographics
NPI:1700561024
Name:GARDNER, TREVOR K (DMD)
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:K
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 N BERNARD ST
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435-2617
Mailing Address - Country:US
Mailing Address - Phone:307-754-3391
Mailing Address - Fax:
Practice Address - Street 1:175 N BERNARD ST
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435-2617
Practice Address - Country:US
Practice Address - Phone:307-754-3391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY16471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice