Provider Demographics
NPI:1851308050
Name:GUDMESTAD, TOM (DDS)
Entity Type:Individual
Prefix:DR
First Name:TOM
Middle Name:
Last Name:GUDMESTAD
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 1:522 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:WEISER
Mailing Address - State:ID
Mailing Address - Zip Code:83672-2205
Mailing Address - Country:US
Mailing Address - Phone:208-549-2213
Mailing Address - Fax:208-549-4187
Practice Address - Street 1:522 E 4TH ST
Practice Address - Street 2:
Practice Address - City:WEISER
Practice Address - State:ID
Practice Address - Zip Code:83672-2205
Practice Address - Country:US
Practice Address - Phone:208-549-2213
Practice Address - Fax:208-549-4187
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD31171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID61937OtherBLUE CROSS ID PAYEE NUMBE
ID000504200Medicaid