Healthcare Provider Details

I. General information

NPI: 1154767259
Provider Name (Legal Business Name): WILLIAM C. GARDNER DDS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2013
Last Update Date: 05/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8200 CARMEL AVE NE STE 101
ALBUQUERQUE NM
87122-2942
US

IV. Provider business mailing address

8200 CARMEL AVE NE STE 101
ALBUQUERQUE NM
87122-2942
US

V. Phone/Fax

Practice location:
  • Phone: 505-828-2669
  • Fax: 505-828-2716
Mailing address:
  • Phone: 505-828-2669
  • Fax: 505-828-2716

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. WILLIAM C GARDNER
Title or Position: PRESIDENT
Credential: DDS
Phone: 505-828-2669