Provider Demographics
NPI:1265535132
Name:DEBOOM, GAYLE WALLACE (DDS)
Entity type:Individual
Prefix:
First Name:GAYLE
Middle Name:WALLACE
Last Name:DEBOOM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9600 VETERANS DRIVE BLDG 85
Mailing Address - Street 2:VA PUGET SOUND - AMER LAKE DIV, (A112)
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98493-5000
Mailing Address - Country:US
Mailing Address - Phone:253-589-4005
Mailing Address - Fax:253-589-4162
Practice Address - Street 1:VA PUGET SOUND AMER LAKE DV # A112
Practice Address - Street 2:9600 VETERANS DRIVE, BLDG. 85
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98493-5000
Practice Address - Country:US
Practice Address - Phone:253-589-4005
Practice Address - Fax:253-589-4162
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA27421122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist