Healthcare Provider Details

I. General information

NPI: 1437446994
Provider Name (Legal Business Name): BRAD A BEAUDOIN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2011
Last Update Date: 10/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

194 MAIN ST STE 1R
AMESBURY MA
01913-3609
US

IV. Provider business mailing address

194 MAIN ST STE 1R
AMESBURY MA
01913-3609
US

V. Phone/Fax

Practice location:
  • Phone: 978-834-6695
  • Fax: 978-834-6945
Mailing address:
  • Phone: 978-834-6695
  • Fax: 978-834-6945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDN1856415
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN1856415
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN4193
License Number StateME
# 4
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number04023
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: