=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679626881
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WENDELL KERRIN GARDNER DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2007
-----------------------------------------------------
Last Update Date | 02/22/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3150 W WARD RD STE 306
-----------------------------------------------------
City | DUNKIRK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20754-3057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-257-5333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3150 W WARD RD STE 306
-----------------------------------------------------
City | DUNKIRK
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20754-3057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-257-5333
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | DS0000008021
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 14029
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------