Provider Demographics
NPI:1194812982
Name:GARDNER, GREGORY JAN (DDS)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:JAN
Last Name:GARDNER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 E 80TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-2709
Mailing Address - Country:US
Mailing Address - Phone:317-257-9389
Mailing Address - Fax:317-253-6820
Practice Address - Street 1:1720 E 80TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-2709
Practice Address - Country:US
Practice Address - Phone:317-257-9389
Practice Address - Fax:317-253-6820
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007551A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice