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General NPI Number Information
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NPI Number | 1316568652
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Entity Type | Individual
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Provider Name | MARY STEPHANY GARDNER CRDH
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Gender | Female
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Dates
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Enumeration Date | 04/28/2020
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Last Update Date | 04/28/2020
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Provider Practice Location Address
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Address Line | 12351 DILLINGHAM SQ
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City | WOODBRIDGE
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State | VA
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Zip | 22192-5251
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Country | US
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Telephone | 239-910-5553
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Fax |
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Provider Business Mailing Address
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Address Line | 50 EBENEZER CHURCH RD APT 13
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City | STAFFORD
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State | VA
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Zip | 22556-3881
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Country | US
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Telephone | 239-910-5553
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number | 0402207699
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License Number State | VA
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