MEDICARE: DR. JEROME M 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	122300000X	Dentist	024454	NY

General Provider Information

NPI Number	:	1295715530
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEROME M GARDNER DDS

Provider Business Mailing Address
First Line	:	970 SUNRISE HWY
Second Line	:
City	:	WEST BABYLON
State	:	NY
Zip	:	11704-6110
Country	:	US
Telephone Number	:	631-669-8855
Fax Number	:	631-669-3497

Provider Business Practice Location Address
First Line	:	970 SUNRISE HWY
Second Line	:
City	:	WEST BABYLON
State	:	NY
Zip	:	11704-6110
Country	:	US
Telephone Number	:	631-669-8855
Fax Number	:	631-669-3497

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

Provider Enumeration Date	:	01/20/2006
Last Update Date	:	07/08/2007

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