Provider Demographics
NPI:1699798371
Name:GARDNER, MICHAEL RAYMOND (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:RAYMOND
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 1:1901 6TH ST SW
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-5104
Mailing Address - Country:US
Mailing Address - Phone:320-231-1290
Mailing Address - Fax:
Practice Address - Street 1:1901 6TH ST SW
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-5104
Practice Address - Country:US
Practice Address - Phone:320-231-1290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN89511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice