Provider Demographics
NPI:1487183265
Name:SE ORTHO MANSFIELD, INC.
Entity Type:Organization
Organization Name:SE ORTHO MANSFIELD, INC.
Other - Org Name:SOUTHEAST ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:GAUDREAULT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:508-880-5891
Mailing Address - Street 1:302 BROADWAY UNIT 6
Mailing Address - Street 2:
Mailing Address - City:RAYNHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02767-1439
Mailing Address - Country:US
Mailing Address - Phone:508-880-5891
Mailing Address - Fax:
Practice Address - Street 1:100 COPELAND DR STE 9
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:MA
Practice Address - Zip Code:02048-1245
Practice Address - Country:US
Practice Address - Phone:508-339-5500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-06
Last Update Date:2017-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MH197021223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty