Provider Demographics
NPI:1871694257
Name:GARDNER, CHAD MARTIN (DDS)
Entity type:Individual
Prefix:DR
First Name:CHAD
Middle Name:MARTIN
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 1:268 HARRINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71220-3026
Mailing Address - Country:US
Mailing Address - Phone:318-281-5972
Mailing Address - Fax:318-281-9964
Practice Address - Street 1:268 HARRINGTON AVE
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-3026
Practice Address - Country:US
Practice Address - Phone:318-281-5972
Practice Address - Fax:318-281-9964
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA56381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1856380Medicaid