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General NPI Number Information
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NPI Number | 1013022003
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Entity Type | Individual
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Provider Name | DOMINIC BRUNO GAULT M.D.
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Gender | Male
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Dates
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Enumeration Date | 08/20/2006
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Last Update Date | 05/14/2021
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Provider Practice Location Address
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Address Line | 200 PATEWOOD DR STE A330
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City | GREENVILLE
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State | SC
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Zip | 29615-3593
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Country | US
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Telephone | 864-454-5660
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Fax | 864-241-9233
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Provider Business Mailing Address
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Address Line | 300 E MCBEE AVE
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City | GREENVILLE
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State | SC
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Zip | 29601-2842
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080S0012X
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Taxonomy Name | Pediatric Sleep Medicine Physician
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License Number | 29065
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License Number State | SC
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