# DR. TOM GUDMESTAD

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- **Entity:** Individual
- **Status:** Active
- **Sole proprietor:** Yes

## Provider details

- **NPI number:** 1851308050
- **Gender:** Man
- **Credential:** DDS

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | D3117 | ID | Yes |

## Other

- **Enumeration date:** 08/01/2006
- **Last updated:** 06/16/2023

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 000504200 | — | ID |
| 01 | — | 61937 | BLUE CROSS ID PAYEE NUMBE | ID |