Provider Demographics
NPI:1073007407
Name:BEAULIEU, LEA (DMD)
Entity Type:Individual
Prefix:
First Name:LEA
Middle Name:
Last Name:BEAULIEU
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 MEADOWBROOK DR UNIT 3
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04038-1384
Mailing Address - Country:US
Mailing Address - Phone:207-636-6039
Mailing Address - Fax:
Practice Address - Street 1:2 STILSON ST
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:ME
Practice Address - Zip Code:04073-3228
Practice Address - Country:US
Practice Address - Phone:207-324-8699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN46281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice