Healthcare Provider Details

I. General information

NPI: 1891955050
Provider Name (Legal Business Name): JOHN A GARDNER, DDS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

1316 OLD 63 S STE. 201
COLUMBIA MO
65201-6092
US

IV. Provider business mailing address

1316 OLD 63 S STE. 201
COLUMBIA MO
65201-6092
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: DR. JOHN ALLEN GARDNER
Title or Position: PEDIATRIC DENTIST/PRESIDENT
Credential: DDS
Phone: 573-443-2544