Provider Demographics
NPI:1720124209
Name:GARDETTO, ROBERT PETER (DDS)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:PETER
Last Name:GARDETTO
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 1:21494 COUNTY ROAD 73
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309-9304
Mailing Address - Country:US
Mailing Address - Phone:763-263-1486
Mailing Address - Fax:
Practice Address - Street 1:1521 NORTHWAY DR
Practice Address - Street 2:SUITE 105
Practice Address - City:ST. CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1223
Practice Address - Country:US
Practice Address - Phone:320-252-8363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND99961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice