MEDICARE: DAVID GUILBEAULT DMD THREE RIVERS DENTAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	2000174030	MO

General Provider Information

NPI Number	:	1366888331
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVID GUILBEAULT DMD THREE RIVERS DENTAL LLC

Provider Business Mailing Address
First Line	:	24 GINGER CREEK PKWY
Second Line	:
City	:	GLEN CARBON
State	:	IL
Zip	:	62034-3502
Country	:	US
Telephone Number	:	618-248-3463
Fax Number	:

Provider Business Practice Location Address
First Line	:	2386 N HIGHWAY 67
Second Line	:	SUITE 2
City	:	FLORISSANT
State	:	MO
Zip	:	63033-2034
Country	:	US
Telephone Number	:	314-355-4140
Fax Number	:

Authorized Official
Title or Position	:	OPERATIONS MANAGER
Name	:	AMY GIBBONS
Credential	:
Telephone Number	:	618-248-2038

Provider Enumeration Date	:	05/17/2013
Last Update Date	:	02/24/2014

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