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:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 W BALTIMORE PIKE
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-2332
Mailing Address - Country:US
Mailing Address - Phone:484-444-2793
Mailing Address - Fax:
Practice Address - Street 1:1003 W BALTIMORE PIKE
Practice Address - Street 2:
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063
Practice Address - Country:US
Practice Address - Phone:484-444-2793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-04
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI029560001223G0001X
PADS0415131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice