Healthcare Provider Details

I. General information

NPI: 1154794758
Provider Name (Legal Business Name): MAINE DENTAL GROUP, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2015
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 STONE ST
AUGUSTA ME
04330-6114
US

IV. Provider business mailing address

290 BRIDGTON RD STE 2
WESTBROOK ME
04092-3754
US

V. Phone/Fax

Practice location:
  • Phone: 207-622-9210
  • Fax:
Mailing address:
  • Phone: 732-207-1689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License NumberDEN4051
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DAVID LEE
Title or Position: COO
Credential:
Phone: 732-207-1689