Healthcare Provider Details

I. General information

NPI: 1134395999
Provider Name (Legal Business Name): WILLIAM GRAHAM GARDNER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2008
Last Update Date: 05/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 WILLOW LAWN DR
RICHMOND VA
23226-1409
US

IV. Provider business mailing address

1206 WILLOW LAWN DR
RICHMOND VA
23226-1409
US

V. Phone/Fax

Practice location:
  • Phone: 804-282-6436
  • Fax: 804-282-8297
Mailing address:
  • Phone: 804-282-6436
  • Fax: 804-282-8297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0401008926
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: