Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | 0401415704 | VA |
Y | 204E00000X | Oral & Maxillofacial Surgeon | 0401415704 | VA |
NPI | 1396279949 |
---|---|
Provider Name | Mark Gardner |
First Address | Glen Allen, VA 23059-5666 |
Second Address | Mechanicsville, VA 23116-3838 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/04/2017 |
Last Update Date | 30/07/2021 |