Healthcare Provider Details

I. General information

NPI: 1740438464
Provider Name (Legal Business Name): PANKAJ THAKKER DMD, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2008
Last Update Date: 03/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 MOUNT AUBURN AVE
AUBURN ME
04210-8521
US

IV. Provider business mailing address

211 MOUNT AUBURN AVE
AUBURN ME
04210-8521
US

V. Phone/Fax

Practice location:
  • Phone: 207-514-7171
  • Fax: 207-514-7177
Mailing address:
  • Phone: 207-514-7171
  • Fax: 207-514-7177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS037336
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberDEN4299
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: