Healthcare Provider Details

I. General information

NPI: 1316568652
Provider Name (Legal Business Name): MARY STEPHANY GARDNER CRDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2020
Last Update Date: 04/28/2020
Certification Date: 04/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12351 DILLINGHAM SQ
WOODBRIDGE VA
22192-5251
US

IV. Provider business mailing address

50 EBENEZER CHURCH RD APT 13
STAFFORD VA
22556-3881
US

V. Phone/Fax

Practice location:
  • Phone: 239-910-5553
  • Fax:
Mailing address:
  • Phone: 239-910-5553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number0402207699
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: