MEDICARE: GARDNER DENTAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	361876	UT

General Provider Information

NPI Number	:	1124554811
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GARDNER DENTAL

Provider Business Mailing Address
First Line	:	525 N FAIRFIELD RD
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041-3339
Country	:	US
Telephone Number	:	801-444-9911
Fax Number	:

Provider Business Practice Location Address
First Line	:	525 N FAIRFIELD RD
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041-3339
Country	:	US
Telephone Number	:	801-444-9911
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANANGER
Name	:	REGAN ANDERSEN
Credential	:
Telephone Number	:	801-444-9911

Provider Enumeration Date	:	05/02/2017
Last Update Date	:	05/02/2017

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