Provider Demographics
NPI:1588086680
Name:GARDNER, MARY KATHERYN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERYN
Last Name:GARDNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18515 MANSEL AVE
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-4642
Mailing Address - Country:US
Mailing Address - Phone:310-507-5756
Mailing Address - Fax:
Practice Address - Street 1:18515 MANSEL AVE
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-4642
Practice Address - Country:US
Practice Address - Phone:310-507-5756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-09
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA68677126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA68677OtherRDA LICENSE