Provider Demographics
NPI:1023854569
Name:GAUDETTE, ERIC DAVID
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:DAVID
Last Name:GAUDETTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 CROMWELL AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-1834
Mailing Address - Country:US
Mailing Address - Phone:860-563-1294
Mailing Address - Fax:
Practice Address - Street 1:412 CROMWELL AVE # WVE
Practice Address - Street 2:
Practice Address - City:ROCKY HILL
Practice Address - State:CT
Practice Address - Zip Code:06067-1834
Practice Address - Country:US
Practice Address - Phone:860-563-1294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-03
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILD00224390200000X
CT144211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program