Healthcare Provider Details

I. General information

NPI: 1770162984
Provider Name (Legal Business Name): NICHOLAS CHARBONNEAU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
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:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDENO3628
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: