MEDICARE: DOUGLAS J GAMMENTHALER 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	122300000X	Dentist	4289	AR

General Provider Information

NPI Number	:	1821582842
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOUGLAS J GAMMENTHALER DDS

Provider Business Mailing Address
First Line	:	2886 W WALNUT ST
Second Line	:
City	:	ROGERS
State	:	AR
Zip	:	72756-0335
Country	:	US
Telephone Number	:	479-899-6444
Fax Number	:	479-899-6605

Provider Business Practice Location Address
First Line	:	2886 W WALNUT ST
Second Line	:
City	:	ROGERS
State	:	AR
Zip	:	72756-0335
Country	:	US
Telephone Number	:	479-899-6444
Fax Number	:	479-899-6605

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

Provider Enumeration Date	:	06/22/2018
Last Update Date	:	06/22/2018

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