Healthcare Provider Details

I. General information

NPI: 1023854569
Provider Name (Legal Business Name): ERIC DAVID GAUDETTE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2024
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 CROMWELL AVE # WVE
ROCKY HILL CT
06067-1834
US

IV. Provider business mailing address

412 CROMWELL AVE
ROCKY HILL CT
06067-1834
US

V. Phone/Fax

Practice location:
  • Phone: 860-563-1294
  • Fax:
Mailing address:
  • Phone: 860-563-1294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number14421
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberLD00224
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: