Provider Demographics
NPI:1285768259
Name:GARY W BARDONNER, DDS, INC
Entity type:Organization
Organization Name:GARY W BARDONNER, DDS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:W
Authorized Official - Last Name:BARDONNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-462-2656
Mailing Address - Street 1:940 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46140-1202
Mailing Address - Country:US
Mailing Address - Phone:317-462-2656
Mailing Address - Fax:
Practice Address - Street 1:940 N STATE ST
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:IN
Practice Address - Zip Code:46140-1202
Practice Address - Country:US
Practice Address - Phone:317-462-2656
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120073171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN12009221OtherSTATE DENTAL LICENSE
IN12007317OtherSTATE DENTAL LICENSE