Provider Demographics
NPI:1366888331
Name:DAVID GUILBEAULT DMD THREE RIVERS DENTAL LLC
Entity type:Organization
Organization Name:DAVID GUILBEAULT DMD THREE RIVERS DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:GIBBONS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-248-2038
Mailing Address - Street 1:24 GINGER CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-3502
Mailing Address - Country:US
Mailing Address - Phone:618-248-3463
Mailing Address - Fax:
Practice Address - Street 1:2386 N HIGHWAY 67
Practice Address - Street 2:SUITE 2
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63033-2034
Practice Address - Country:US
Practice Address - Phone:314-355-4140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-17
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20001740301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty