Provider Demographics
NPI:1831353606
Name:GARDNER, RANDOLPH PAUL (DMD)
Entity type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:PAUL
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 1:449 PLEASANT HILL RD NW
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-2770
Mailing Address - Country:US
Mailing Address - Phone:770-564-9906
Mailing Address - Fax:770-564-9907
Practice Address - Street 1:449 PLEASANT HILL RD NW
Practice Address - Street 2:SUITE 101
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-2770
Practice Address - Country:US
Practice Address - Phone:770-564-9906
Practice Address - Fax:770-564-9907
Is Sole Proprietor?:No
Enumeration Date:2008-07-10
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN11602122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist