Provider Demographics
NPI:1912040999
Name:SOUDAN, GARY JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:JAMES
Last Name:SOUDAN
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 1:2080 MYERS ST
Mailing Address - Street 2:
Mailing Address - City:OROVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95966-5341
Mailing Address - Country:US
Mailing Address - Phone:530-533-3142
Mailing Address - Fax:530-533-3158
Practice Address - Street 1:2080 MYERS STREET
Practice Address - Street 2:2080 MYERS STREET
Practice Address - City:OROVILLE
Practice Address - State:CA
Practice Address - Zip Code:95966
Practice Address - Country:US
Practice Address - Phone:530-533-3142
Practice Address - Fax:530-533-3158
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39566122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist