Provider Demographics
NPI:1013926716
Name:CHARBONNEAU, GAETAN DONALD (DMD)
Entity Type:Individual
Prefix:
First Name:GAETAN
Middle Name:DONALD
Last Name:CHARBONNEAU
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 1:24 SALT POND RD SUITE A2
Mailing Address - Street 2:SOUTH KINGSTOWN OFFICE PARK
Mailing Address - City:WAKEFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02879
Mailing Address - Country:US
Mailing Address - Phone:401-783-4223
Mailing Address - Fax:401-783-1228
Practice Address - Street 1:24 SALT POND RD SUITE A2
Practice Address - Street 2:SOUTH KINGSTOWN OFFICE PARK
Practice Address - City:WAKEFIELD
Practice Address - State:RI
Practice Address - Zip Code:02879
Practice Address - Country:US
Practice Address - Phone:401-783-4223
Practice Address - Fax:401-783-1228
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN01889122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI84185OtherBLUE CROSS DENTAL