Provider Demographics
NPI:1477990182
Name:GOUDREAU, DONALD JEAN III (DMD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:JEAN
Last Name:GOUDREAU
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 RACE ST
Mailing Address - Street 2:APT 2E
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-2332
Mailing Address - Country:US
Mailing Address - Phone:262-366-6936
Mailing Address - Fax:
Practice Address - Street 1:245 N 15TH ST
Practice Address - Street 2:MAIL STOP MS 467, ROOM 7318
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-1192
Practice Address - Country:US
Practice Address - Phone:215-762-5630
Practice Address - Fax:215-762-8389
Is Sole Proprietor?:No
Enumeration Date:2013-06-04
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAUNKNOWN AT THIS TIME1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery