Provider Demographics
NPI:1376672105
Name:GAUTHIER, THOMAS G (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:G
Last Name:GAUTHIER
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 1:165 NW 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:JOHN DAY
Mailing Address - State:OR
Mailing Address - Zip Code:97845-1101
Mailing Address - Country:US
Mailing Address - Phone:541-575-0363
Mailing Address - Fax:541-575-1638
Practice Address - Street 1:2530 NW MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-5510
Practice Address - Country:US
Practice Address - Phone:541-673-6511
Practice Address - Fax:541-673-6511
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD55061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice