MEDICARE: DR. TIMOTHY ELMER GARDNER DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	16499	TX

General Provider Information

NPI Number	:	1104043942
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIMOTHY ELMER GARDNER DDS

Provider Business Mailing Address
First Line	:	2210 N FRAZIER ST STE 120
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77303-1701
Country	:	US
Telephone Number	:	936-539-3636
Fax Number	:	936-539-3639

Provider Business Practice Location Address
First Line	:	2210 N FRAZIER ST STE 120
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77303-1701
Country	:	US
Telephone Number	:	936-539-3636
Fax Number	:	936-539-3639

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/20/2007
Last Update Date	:	08/21/2017

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