Provider Demographics
NPI:1477092294
Name:GAUTIER FAMILY DENTAL
Entity Type:Organization
Organization Name:GAUTIER FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:LAKE
Authorized Official - Last Name:GARNER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:601-271-8710
Mailing Address - Street 1:4358 LINCOLN ROAD EXT STE 20
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-3275
Mailing Address - Country:US
Mailing Address - Phone:601-271-8710
Mailing Address - Fax:
Practice Address - Street 1:2808 HIGHWAY 90 STE 1
Practice Address - Street 2:
Practice Address - City:GAUTIER
Practice Address - State:MS
Practice Address - Zip Code:39553-5169
Practice Address - Country:US
Practice Address - Phone:228-497-2424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty