=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982032579
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GARDNER & GARDNER DDS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2013
-----------------------------------------------------
Last Update Date | 10/17/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1617 E 1ST ST SUITE A
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92701-6385
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-617-5048
-----------------------------------------------------
Fax | 714-617-5041
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1617 E 1ST ST SUITE A
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92701-6385
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-617-5048
-----------------------------------------------------
Fax | 714-617-5041
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PROVIDER
-----------------------------------------------------
Name | MRS. ASAL GARDNER
-----------------------------------------------------
Credential | D.D.S
-----------------------------------------------------
Telephone | 909-800-7195
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 61418
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------