Healthcare Provider Details

I. General information

NPI: 1144688532
Provider Name (Legal Business Name): ANDREY GAIDUCHIK D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/01/2016
Last Update Date: 01/03/2023
Certification Date: 01/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5740 WINDMILL WAY STE 16
CARMICHAEL CA
95608-1379
US

IV. Provider business mailing address

1350 W ROBINHOOD DR STE 20
STOCKTON CA
95207-5519
US

V. Phone/Fax

Practice location:
  • Phone: 916-331-0841
  • Fax:
Mailing address:
  • Phone: 209-477-6700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number103200
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: