Provider Demographics
NPI:1114095361
Name:SOUTHEAST ORTHODONTICS, INC.
Entity Type:Organization
Organization Name:SOUTHEAST ORTHODONTICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:GAUDREAULT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:508-587-8623
Mailing Address - Street 1:841 BELMONT STREET
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02030
Mailing Address - Country:US
Mailing Address - Phone:508-587-8623
Mailing Address - Fax:
Practice Address - Street 1:841 BELMONT ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5545
Practice Address - Country:US
Practice Address - Phone:508-587-8623
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA19702261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental