Healthcare Provider Details

I. General information

NPI: 1225740988
Provider Name (Legal Business Name): GAETAN D. CHARBONNEAU, DMD, LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2022
Last Update Date: 12/14/2022
Certification Date: 12/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 SALT POND RD STE A2
WAKEFIELD RI
02879-4304
US

IV. Provider business mailing address

24 SALT POND RD STE A2
WAKEFIELD RI
02879-4304
US

V. Phone/Fax

Practice location:
  • Phone: 401-783-4223
  • Fax: 401-783-1228
Mailing address:
  • Phone: 401-783-4223
  • Fax: 401-783-1228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: GAETAN CHARBONNEAU
Title or Position: DENTIST/ PRESIDENT
Credential: DMD
Phone: 401-783-4223