Healthcare Provider Details

I. General information

NPI: 1861655953
Provider Name (Legal Business Name): QUINTON WAYNE GARDNER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 01/10/2020
Certification Date: 01/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

944 N GILBERT RD STE 104
MESA AZ
85203-5836
US

IV. Provider business mailing address

944 N GILBERT RD STE 104
MESA AZ
85203-5836
US

V. Phone/Fax

Practice location:
  • Phone: 480-649-7200
  • Fax: 480-649-7219
Mailing address:
  • Phone: 480-649-7200
  • Fax: 480-649-7219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD9119
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD07791
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD7791
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: