Provider Demographics
NPI:1871838227
Name:GOUGH, THOMAS LELAND (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:LELAND
Last Name:GOUGH
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 1:1315 N RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-4509
Mailing Address - Country:US
Mailing Address - Phone:815-385-1360
Mailing Address - Fax:815-385-3879
Practice Address - Street 1:1315 N RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-4509
Practice Address - Country:US
Practice Address - Phone:815-385-1360
Practice Address - Fax:815-385-3879
Is Sole Proprietor?:No
Enumeration Date:2012-12-11
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019-021569122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist