Provider Demographics
NPI:1811135296
Name:WILLIAM B. GARDNER, D.M.D. P.C.
Entity type:Organization
Organization Name:WILLIAM B. GARDNER, D.M.D. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTAL HYGIENIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:FOUNTAIN
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:706-647-7914
Mailing Address - Street 1:507 W GORDON ST
Mailing Address - Street 2:
Mailing Address - City:THOMASTON
Mailing Address - State:GA
Mailing Address - Zip Code:30286-3424
Mailing Address - Country:US
Mailing Address - Phone:706-647-7914
Mailing Address - Fax:706-647-4543
Practice Address - Street 1:507 W GORDON ST
Practice Address - Street 2:
Practice Address - City:THOMASTON
Practice Address - State:GA
Practice Address - Zip Code:30286-3424
Practice Address - Country:US
Practice Address - Phone:706-647-7914
Practice Address - Fax:706-647-4543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-23
Last Update Date:2009-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA111331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100417OtherAVESIS
GA9181304OtherDORAL
GA00545124AMedicaid