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General NPI Number Information
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NPI Number | 1578984662
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Entity Type | Organization
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Legal Business Name | SOUTHEAST PEDIATRIC DENTISTRY AND ORTHODONTICS PC
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Dates
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Enumeration Date | 12/17/2013
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Last Update Date | 12/17/2013
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Provider Practice Location Address
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Address Line | 408 STATE RD STE 730
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City | DARTMOUTH
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State | MA
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Zip | 02747-4302
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Country | US
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Telephone | 508-990-3000
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Fax |
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Provider Business Mailing Address
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Address Line | 841 BELMONT ST
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City | BROCKTON
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State | MA
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Zip | 02301-5545
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Country | US
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Telephone | 508-587-8623
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. BRIAN RICHARD GAUDREAULT
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Credential | DMD
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Telephone | 508-345-7075
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 1855240
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License Number State | MA
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 19702
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License Number State | MA
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