Healthcare Provider Details

I. General information

NPI: 1114153939
Provider Name (Legal Business Name): KENNEBEC VALLEY FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2009
Last Update Date: 11/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 WATER ST
AUGUSTA ME
04330-4645
US

IV. Provider business mailing address

6 E CHESTNUT ST STE 420
AUGUSTA ME
04330-5743
US

V. Phone/Fax

Practice location:
  • Phone: 207-623-3400
  • Fax: 207-623-3440
Mailing address:
  • Phone: 207-623-3400
  • Fax: 207-623-3440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number3095
License Number StateME

VIII. Authorized Official

Name: MS. KIMBERLEY GORDON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 207-623-3400