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General NPI Number Information
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NPI Number | 1366720922
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Entity Type | Individual
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Provider Name | DUSTIN J GARDNER O.D.
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Gender | Male
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Dates
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Enumeration Date | 08/01/2011
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Last Update Date | 10/04/2016
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Provider Practice Location Address
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Address Line | 105 MOREY DR
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City | MARYSVILLE
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State | OH
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Zip | 43040-1647
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Country | US
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Telephone | 937-642-1916
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Fax |
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Provider Business Mailing Address
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Address Line | 15933 CLAYTON RD SUITE 201
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City | BALLWIN
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State | MO
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Zip | 63011-2172
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Country | US
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Telephone | 636-200-4393
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Fax | 636-527-0766
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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 | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 6041
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License Number State | OH
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