Provider Demographics
NPI:1033267208
Name:THIBAULT, GERARD JOSEPH (DDS)
Entity Type:Individual
Prefix:DR
First Name:GERARD
Middle Name:JOSEPH
Last Name:THIBAULT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 SULLIVAN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104-2415
Mailing Address - Country:US
Mailing Address - Phone:413-785-5566
Mailing Address - Fax:413-785-5568
Practice Address - Street 1:43 SULLIVAN ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-2415
Practice Address - Country:US
Practice Address - Phone:413-785-5566
Practice Address - Fax:413-785-5568
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA109301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice