MEDICARE: CASEY GARDNER RDH

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	124Q00000X	Dental Hygienist	4531	KY

General Provider Information

NPI Number	:	1528418506
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CASEY GARDNER RDH

Provider Business Mailing Address
First Line	:	2441 21ST ST
Second Line	:
City	:	FORT CAMPBELL
State	:	KY
Zip	:	42223-5582
Country	:	US
Telephone Number	:	270-798-8751
Fax Number	:	270-956-0266

Provider Business Practice Location Address
First Line	:	3603 INDIANA AVE
Second Line	:
City	:	FORT CAMPBELL
State	:	KY
Zip	:	42223-5803
Country	:	US
Telephone Number	:	270-798-3544
Fax Number	:	270-956-0266

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

Provider Enumeration Date	:	06/21/2016
Last Update Date	:	06/07/2022

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