Healthcare Provider Details

I. General information

NPI: 1942374491
Provider Name (Legal Business Name): ROBERT C. GAUDRY D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1718 S. MILLENIUM WAY
MERIDIAN ID
83642-1511
US

IV. Provider business mailing address

1718 S. MILLENIUM WAY
MERIDIAN ID
83642-1511
US

V. Phone/Fax

Practice location:
  • Phone: 208-887-1053
  • Fax: 208-884-5346
Mailing address:
  • Phone: 208-887-1053
  • Fax: 208-884-5346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD-1954-OR
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: