Healthcare Provider Details

I. General information

NPI: 1043317720
Provider Name (Legal Business Name): ANDREW D GAMACHE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 WALNUT AVE
SAN DIEGO CA
92103-4978
US

IV. Provider business mailing address

306 WALNUT AVE STE 31
SAN DIEGO CA
92103-4936
US

V. Phone/Fax

Practice location:
  • Phone: 619-220-0866
  • Fax: 619-220-0870
Mailing address:
  • Phone: 619-220-0866
  • Fax: 619-220-0870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number23448
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number54255
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number54255
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: