Provider Demographics
NPI:1871627190
Name:GARDNER DENTAL GROUP
Entity type:Organization
Organization Name:GARDNER DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:K
Authorized Official - Last Name:STOWELL
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:978-249-8545
Mailing Address - Street 1:49 CROSS STREET EXT
Mailing Address - Street 2:
Mailing Address - City:GARDNER
Mailing Address - State:MA
Mailing Address - Zip Code:01440-2209
Mailing Address - Country:US
Mailing Address - Phone:978-632-5659
Mailing Address - Fax:978-632-5713
Practice Address - Street 1:49 CROSS STREET EXT
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440-2209
Practice Address - Country:US
Practice Address - Phone:978-632-5659
Practice Address - Fax:978-632-5713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA127361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA36564OtherUNITED CONCORDIA
MAX12692OtherBLUECROSS BLUESHIELD OF MA
MA9794671Medicaid
MA1250OtherDELTA DENTAL