Healthcare Provider Details

I. General information

NPI: 1194574723
Provider Name (Legal Business Name): CREATIVE DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2024
Last Update Date: 05/15/2024
Certification Date: 05/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 BROADWAY
BANGOR ME
04401-2403
US

IV. Provider business mailing address

290 BRIDGTON RD STE 2
WESTBROOK ME
04092-3754
US

V. Phone/Fax

Practice location:
  • Phone: 207-942-3000
  • Fax: 207-992-4054
Mailing address:
  • Phone: 732-207-1689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
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