Basic Information
| Provider Information | |||||||||
| NPI: | 1881205904 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARDNER | ||||||||
| FirstName: | BIANCA | ||||||||
| MiddleName: | ELISA | ||||||||
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| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2940 STANLEY RD | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782342740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2102954095 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | BUILDING 9900 LINCOLN STREET | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539684079 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2020 | ||||||||
| LastUpdateDate: | 11/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 10470 | KY | Y | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 10470 | 01 | KY | LICENSE | OTHER |