Provider Demographics
NPI:1649675810
Name:BEAULIEU, MICHELLE (DMD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:
Last Name:BEAULIEU
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 TYNG ST APT 3
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3995
Mailing Address - Country:US
Mailing Address - Phone:207-772-4359
Mailing Address - Fax:
Practice Address - Street 1:130 CENTRE ST STE 2
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:ME
Practice Address - Zip Code:04530-2598
Practice Address - Country:US
Practice Address - Phone:207-443-6255
Practice Address - Fax:207-389-4587
Is Sole Proprietor?:No
Enumeration Date:2014-10-29
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI025768001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice