Provider Demographics
NPI:1942374491
Name:GAUDRY, ROBERT C (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:C
Last Name:GAUDRY
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1718 S. MILLENIUM WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1511
Mailing Address - Country:US
Mailing Address - Phone:208-887-1053
Mailing Address - Fax:208-884-5346
Practice Address - Street 1:1718 S. MILLENIUM WAY
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1511
Practice Address - Country:US
Practice Address - Phone:208-887-1053
Practice Address - Fax:208-884-5346
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-1954-OR1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics