MEDICARE: DR. THOMAS G GAUTHIER DDS

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	D5506	OR

General Provider Information

NPI Number	:	1376672105
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS G GAUTHIER DDS

Provider Business Mailing Address
First Line	:	165 NW 1ST AVE
Second Line	:
City	:	JOHN DAY
State	:	OR
Zip	:	97845-1101
Country	:	US
Telephone Number	:	541-575-0363
Fax Number	:	541-575-1638

Provider Business Practice Location Address
First Line	:	2530 NW MEDICAL PARK DR
Second Line	:
City	:	ROSEBURG
State	:	OR
Zip	:	97471-5510
Country	:	US
Telephone Number	:	541-673-6511
Fax Number	:	541-673-6511

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/05/2007
Last Update Date	:	05/01/2012

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