MEDICARE: SOUTHERN MAINE PEDIATRIC DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	3767	ME

General Provider Information

NPI Number	:	1184814568
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN MAINE PEDIATRIC DENTISTRY

Provider Business Mailing Address
First Line	:	75 JOHN ROBERTS RD
Second Line	:	SUIT 10B
City	:	SOUTH PORTLAND
State	:	ME
Zip	:	04106-6914
Country	:	US
Telephone Number	:	207-773-3111
Fax Number	:

Provider Business Practice Location Address
First Line	:	75 JOHN ROBERTS RD
Second Line	:	SUIT 10B
City	:	SOUTH PORTLAND
State	:	ME
Zip	:	04106-6914
Country	:	US
Telephone Number	:	207-773-3111
Fax Number	:

Authorized Official
Title or Position	:	PEDIATRIC DENTIST
Name	:	DR. WHITNEY RALSTON WIGNALL
Credential	:	DMD
Telephone Number	:	207-773-3111

Provider Enumeration Date	:	07/31/2007
Last Update Date	:	07/31/2007

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