Provider Demographics
NPI:1174610059
Name:LATHAM, GARY M (DDS)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:M
Last Name:LATHAM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1260 N DUTTON AVE
Mailing Address - Street 2:#290
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4659
Mailing Address - Country:US
Mailing Address - Phone:707-527-7400
Mailing Address - Fax:707-527-7427
Practice Address - Street 1:1260 N DUTTON AVE
Practice Address - Street 2:#290
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4659
Practice Address - Country:US
Practice Address - Phone:707-527-7400
Practice Address - Fax:707-527-7427
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA25570122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist