Healthcare Provider Details

I. General information

NPI: 1437558137
Provider Name (Legal Business Name): GARDNER PEDIATRIC DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2014
Last Update Date: 12/11/2024
Certification Date: 12/11/2024
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: 417-396-7318
  • Fax:
Mailing address:
  • Phone: 417-396-7318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number2012019137
License Number StateMO

VIII. Authorized Official

Name: DR. JESSE NATHANIEL GARDNER
Title or Position: OWNER
Credential: D.M.D.
Phone: 417-719-7862