Provider Demographics
NPI:1801559489
Name:GOULET, CARMEN LISA (DMD)
Entity type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:LISA
Last Name:GOULET
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 1:1384 SW SAINT LUCIE WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-2109
Mailing Address - Country:US
Mailing Address - Phone:772-249-0488
Mailing Address - Fax:772-249-4695
Practice Address - Street 1:1384 SW SAINT LUCIE WEST BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2109
Practice Address - Country:US
Practice Address - Phone:772-249-0488
Practice Address - Fax:772-249-4695
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN264991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice