MEDICARE: TINA F. GAULDIN RDH

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
1	124Q00000X	Dental Hygienist	5200	NC
2	124Q00000X	Dental Hygienist	0402004170	VA

General Provider Information

NPI Number	:	1982358537
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TINA F. GAULDIN RDH

Provider Business Mailing Address
First Line	:	1008 S MAIN ST
Second Line	:
City	:	DANVILLE
State	:	VA
Zip	:	24541-4004
Country	:	US
Telephone Number	:	434-797-8548
Fax Number	:

Provider Business Practice Location Address
First Line	:	1008 S MAIN ST
Second Line	:
City	:	DANVILLE
State	:	VA
Zip	:	24541-4004
Country	:	US
Telephone Number	:	434-797-8548
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/11/2022
Last Update Date	:	02/11/2022

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