Provider Demographics
NPI:1407556707
Name:BEAUCHAMP, GERARD JEAN-LUC (DMD)
Entity Type:Individual
Prefix:
First Name:GERARD
Middle Name:JEAN-LUC
Last Name:BEAUCHAMP
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 1:9408 NW 54TH DORAL CIRCLE LN
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-2048
Mailing Address - Country:US
Mailing Address - Phone:305-562-0374
Mailing Address - Fax:
Practice Address - Street 1:9408 NW 54TH DORAL CIRCLE LN
Practice Address - Street 2:
Practice Address - City:DORAL
Practice Address - State:FL
Practice Address - Zip Code:33178-2048
Practice Address - Country:US
Practice Address - Phone:305-562-0374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-06
Last Update Date:2023-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program