Provider Demographics
NPI:1114943479
Name:BEAUDETTE, LOUIS ANTHONY (DMD)
Entity Type:Individual
Prefix:
First Name:LOUIS
Middle Name:ANTHONY
Last Name:BEAUDETTE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 EAST MAIN ST.
Mailing Address - Street 2:BOX 937
Mailing Address - City:WILMINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05363-0937
Mailing Address - Country:US
Mailing Address - Phone:802-464-5817
Mailing Address - Fax:802-464-1103
Practice Address - Street 1:108 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:VT
Practice Address - Zip Code:05363
Practice Address - Country:US
Practice Address - Phone:802-464-5817
Practice Address - Fax:802-464-1103
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT016-00005881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0001693Medicaid