Provider Demographics
NPI:1871150060
Name:COULDWELL, SANDRINE MARIE (DDS, MS)
Entity type:Individual
Prefix:
First Name:SANDRINE
Middle Name:MARIE
Last Name:COULDWELL
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 QUINCY SHORE DR UNIT 112
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02171-2943
Mailing Address - Country:US
Mailing Address - Phone:801-560-3658
Mailing Address - Fax:
Practice Address - Street 1:151 MERRIMAC ST STE 100
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-4717
Practice Address - Country:US
Practice Address - Phone:617-982-2233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-22
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1859122122300000X, 1223P0300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
0334339OtherUNIVERSITY OF UTAH SCHOOL OF DENTISTRY UID
252534OtherUNIVERSITY OF NORTH CAROLINA UID