Provider Demographics
NPI:1790316164
Name:GAUTHIER, MEGAN
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:GAUTHIER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:RAMSEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07446-1030
Mailing Address - Country:US
Mailing Address - Phone:201-675-7190
Mailing Address - Fax:
Practice Address - Street 1:89 N MAPLE AVE
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3235
Practice Address - Country:US
Practice Address - Phone:201-797-8899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-04
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI028221001223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program