Healthcare Provider Details

I. General information

NPI: 1376672105
Provider Name (Legal Business Name): THOMAS G GAUTHIER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 05/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2530 NW MEDICAL PARK DR
ROSEBURG OR
97471-5510
US

IV. Provider business mailing address

165 NW 1ST AVE
JOHN DAY OR
97845-1101
US

V. Phone/Fax

Practice location:
  • Phone: 541-673-6511
  • Fax: 541-673-6511
Mailing address:
  • Phone: 541-575-0363
  • Fax: 541-575-1638

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD5506
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: