Provider Demographics
NPI:1528298429
Name:GARDNER, VIVIAN SHIZUE (DDS)
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:SHIZUE
Last Name:GARDNER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 O ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20001-1259
Mailing Address - Country:US
Mailing Address - Phone:202-797-8806
Mailing Address - Fax:
Practice Address - Street 1:60 O ST NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20001-1259
Practice Address - Country:US
Practice Address - Phone:202-797-8806
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-26
Last Update Date:2009-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDEN1000717122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist