Healthcare Provider Details

I. General information

NPI: 1215083696
Provider Name (Legal Business Name): JOHN ALLEN GARDNER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 06/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1316 OLD 63 SOUTH SUITE 201
COLUMBIA MO
65201-6045
US

IV. Provider business mailing address

1316 OLD 63 SOUTH SUITE 201
COLUMBIA MO
65201-6045
US

V. Phone/Fax

Practice location:
  • Phone: 573-443-2544
  • Fax: 573-815-0840
Mailing address:
  • Phone: 573-443-2544
  • Fax: 573-815-0840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number10937
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: