Provider Demographics
NPI:1215446521
Name:RAE A. GAUTHIER, DDS, LLC DBA PONCHATOULA FAMILY DENTISTRY
Entity type:Organization
Organization Name:RAE A. GAUTHIER, DDS, LLC DBA PONCHATOULA FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:RAE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GAUTHIER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:985-386-8454
Mailing Address - Street 1:430 E PINE ST
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454-2544
Mailing Address - Country:US
Mailing Address - Phone:985-687-3806
Mailing Address - Fax:985-386-8467
Practice Address - Street 1:430 E PINE ST
Practice Address - Street 2:
Practice Address - City:PONCHATOULA
Practice Address - State:LA
Practice Address - Zip Code:70454-2544
Practice Address - Country:US
Practice Address - Phone:985-687-3806
Practice Address - Fax:985-386-8467
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA5909261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1859095Medicaid