Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223X0400X | Orthodontists | 23133 | FL |
NPI | 1063811644 |
---|---|
Provider Name | Thomas Levier Gardner |
First Address | Orange Park, FL 32065-5290 |
Second Address | Orange Park, FL 32065-5290 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/08/2014 |
Last Update Date | 04/08/2020 |