Provider Demographics
NPI:1215075577
Name:GAUTHIER, MATTHEW EMMETT (DDS)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:EMMETT
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 1:1600 W CENTRAL ROAD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HTS
Mailing Address - State:IL
Mailing Address - Zip Code:60005
Mailing Address - Country:US
Mailing Address - Phone:847-392-6220
Mailing Address - Fax:847-392-6236
Practice Address - Street 1:1600 W CENTRAL ROAD
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60005
Practice Address - Country:US
Practice Address - Phone:847-392-6220
Practice Address - Fax:847-392-6236
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019025795122300000X
IL0210021231223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U95172Medicare UPIN