Provider Demographics
NPI:1801912662
Name:GAUTHIER, JACOB E (DDS)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:E
Last Name:GAUTHIER
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 1:538 TUNICA DR W
Mailing Address - Street 2:
Mailing Address - City:MARKSVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71351-2627
Mailing Address - Country:US
Mailing Address - Phone:318-253-8529
Mailing Address - Fax:318-253-8595
Practice Address - Street 1:538 TUNICA DR W
Practice Address - Street 2:
Practice Address - City:MARKSVILLE
Practice Address - State:LA
Practice Address - Zip Code:71351-2627
Practice Address - Country:US
Practice Address - Phone:318-253-8529
Practice Address - Fax:318-253-8595
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA51031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1851035Medicaid