Provider Demographics
NPI:1346442647
Name:THAYER, W. RICHARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:W.
Middle Name:RICHARD
Last Name:THAYER
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 1:199 COUNTRY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-5551
Mailing Address - Country:US
Mailing Address - Phone:707-544-5144
Mailing Address - Fax:707-544-5123
Practice Address - Street 1:511 HAYES LN
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94952-4011
Practice Address - Country:US
Practice Address - Phone:707-763-2654
Practice Address - Fax:707-763-3141
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA224231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice