Provider Demographics
NPI:1225002652
Name:GAUDRY, DEREK ADAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:ADAM
Last Name:GAUDRY
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 1:2018 ARMY BLVD, APT A
Mailing Address - Street 2:USA DENTAC
Mailing Address - City:FT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234
Mailing Address - Country:US
Mailing Address - Phone:210-221-0826
Mailing Address - Fax:
Practice Address - Street 1:2018 ARMY BLVD, APT A
Practice Address - Street 2:USA DENTAC
Practice Address - City:FT SAM HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:78234
Practice Address - Country:US
Practice Address - Phone:210-221-0826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD105122300000X
SDD05211223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
No122300000XDental ProvidersDentist