Healthcare Provider Details

I. General information

NPI: 1871838227
Provider Name (Legal Business Name): THOMAS LELAND GOUGH D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2012
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 N RIVERSIDE DR
MCHENRY IL
60050-4509
US

IV. Provider business mailing address

1315 N RIVERSIDE DR
MCHENRY IL
60050-4509
US

V. Phone/Fax

Practice location:
  • Phone: 815-385-1360
  • Fax: 815-385-3879
Mailing address:
  • Phone: 815-385-1360
  • Fax: 815-385-3879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number019-021569
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: