Provider Demographics
NPI:1295715530
Name:GARDNER, JEROME M (DDS)
Entity type:Individual
Prefix:DR
First Name:JEROME
Middle Name:M
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 1:970 SUNRISE HWY
Mailing Address - Street 2:
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-6110
Mailing Address - Country:US
Mailing Address - Phone:631-669-8855
Mailing Address - Fax:631-669-3497
Practice Address - Street 1:970 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-6110
Practice Address - Country:US
Practice Address - Phone:631-669-8855
Practice Address - Fax:631-669-3497
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024454122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist