Provider Demographics
NPI:1184732679
Name:GAUDET, EDWARD LEON SR (DDS)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:LEON
Last Name:GAUDET
Suffix:SR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1143
Mailing Address - Street 2:407 FRANKLIN STREET
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39121
Mailing Address - Country:US
Mailing Address - Phone:601-442-5476
Mailing Address - Fax:601-442-5477
Practice Address - Street 1:407 FRANKLIN STREET
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39121
Practice Address - Country:US
Practice Address - Phone:601-442-5476
Practice Address - Fax:601-442-5477
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-26
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS129267122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00060965Medicaid