Provider Demographics
NPI:1285756684
Name:BREAULT, MICHAEL R (DDS)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:R
Last Name:BREAULT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1368 UNION ST
Mailing Address - Street 2:
Mailing Address - City:SCHENECTADY
Mailing Address - State:NY
Mailing Address - Zip Code:12308-3017
Mailing Address - Country:US
Mailing Address - Phone:518-374-4486
Mailing Address - Fax:518-393-1612
Practice Address - Street 1:1368 UNION ST
Practice Address - Street 2:
Practice Address - City:SCHENECTADY
Practice Address - State:NY
Practice Address - Zip Code:12308-3017
Practice Address - Country:US
Practice Address - Phone:518-374-4486
Practice Address - Fax:518-393-1612
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY034453-11223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics