Provider Demographics
NPI:1609515253
Name:GOUDEAU, THEKLA MELI (RDH)
Entity type:Individual
Prefix:
First Name:THEKLA
Middle Name:MELI
Last Name:GOUDEAU
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 6TH AVE UNIT 108
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31901-2652
Mailing Address - Country:US
Mailing Address - Phone:704-962-7969
Mailing Address - Fax:
Practice Address - Street 1:1510 6TH AVE UNIT 108
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-2652
Practice Address - Country:US
Practice Address - Phone:704-962-7969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-01
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS12900124Q00000X
GADH044923124Q00000X
NC11719124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist