Provider Demographics
NPI:1588794499
Name:ST GERMAIN, ANDRE EUGENE (DMD MSCD)
Entity type:Individual
Prefix:DR
First Name:ANDRE
Middle Name:EUGENE
Last Name:ST GERMAIN
Suffix:
Gender:M
Credentials:DMD MSCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 151
Mailing Address - Street 2:30 FRANKLIN TERRACE
Mailing Address - City:VINEYARD HAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02568-0151
Mailing Address - Country:US
Mailing Address - Phone:508-693-0307
Mailing Address - Fax:
Practice Address - Street 1:EMERALD ST
Practice Address - Street 2:TUFTS DENTAL FACILITY AT WRENTHAM
Practice Address - City:WRENTHAM
Practice Address - State:MA
Practice Address - Zip Code:02093-1902
Practice Address - Country:US
Practice Address - Phone:508-384-8987
Practice Address - Fax:508-384-6594
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN106081122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MADN106081OtherMASS DENTAL LICENSE