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NPI Code Detail

MEDICARE: DR. DEREK ADAM GAUDRY DDS

MEDICARE: DR. DEREK ADAM GAUDRY DDS
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1122300000XDentist105SD
21223E0200XEndodonticsD0521SD

General Provider Information

NPI Number : 1225002652
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. DEREK ADAM GAUDRY DDS
Provider Business Mailing Address
First Line : 2018 ARMY BLVD, APT A
Second Line : USA DENTAC
City : FT SAM HOUSTON
State : TX
Zip : 78234
Country : US
Telephone Number : 210-221-0826
Fax Number :
Provider Business Practice Location Address
First Line : 2018 ARMY BLVD, APT A
Second Line : USA DENTAC
City : FT SAM HOUSTON
State : TX
Zip : 78234
Country : US
Telephone Number : 210-221-0826
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/14/2006
Last Update Date : 06/19/2014

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