=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548536832
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROBERT W. GARDNER, D.D.S. INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2012
-----------------------------------------------------
Last Update Date | 03/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4490 INDIANOLA AVE
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43214-2244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-262-8180
-----------------------------------------------------
Fax | 614-262-2883
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4490 INDIANOLA AVE
-----------------------------------------------------
City | COLUMBUS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43214-2244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-262-8180
-----------------------------------------------------
Fax | 614-262-2883
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | NATALIE SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 614-262-8180
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 30020068
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------