Healthcare Provider Details

I. General information

NPI: 1992050132
Provider Name (Legal Business Name): JESSE NATHANIEL GARDNER D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2012
Last Update Date: 03/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 E WALNUT LAWN ST
SPRINGFIELD MO
65804-4202
US

IV. Provider business mailing address

1250 E WALNUT LAWN ST
SPRINGFIELD MO
65804-4202
US

V. Phone/Fax

Practice location:
  • Phone: 417-719-7862
  • Fax: 417-719-7861
Mailing address:
  • Phone: 417-719-7862
  • Fax: 417-719-7861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2012019137
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: