MEDICARE: DAVID GARDNER DMD

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	122300000X	Dentist	DS037861	PA

General Provider Information

NPI Number	:	1861721938
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID GARDNER DMD

Provider Business Mailing Address
First Line	:	1714 LOCUST ST
Second Line	:	SUITE 2
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-6153
Country	:	US
Telephone Number	:	215-732-2490
Fax Number	:	215-732-2490

Provider Business Practice Location Address
First Line	:	1714 LOCUST ST
Second Line	:	SUITE 2
City	:	PHILADELPHIA
State	:	PA
Zip	:	19103-6153
Country	:	US
Telephone Number	:	215-732-2490
Fax Number	:	215-732-2490

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/18/2009
Last Update Date	:	06/07/2012

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