Provider Demographics
NPI:1205513728
Name:GAMACHE, NATHANIEL
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:GAMACHE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 N MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:MCPHERSON
Mailing Address - State:KS
Mailing Address - Zip Code:67460-3325
Mailing Address - Country:US
Mailing Address - Phone:620-417-0137
Mailing Address - Fax:
Practice Address - Street 1:700 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:MCPHERSON
Practice Address - State:KS
Practice Address - Zip Code:67460-3325
Practice Address - Country:US
Practice Address - Phone:620-417-0137
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS62156122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist