Healthcare Provider Details

I. General information

NPI: 1740731470
Provider Name (Legal Business Name): DAVID C HALUSKA DMD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2016
Last Update Date: 10/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 STILLWATER AVE SUITE 6
BANGOR ME
04401-3984
US

IV. Provider business mailing address

12 STILLWATER AVE SUITE 6
BANGOR ME
04401-3984
US

V. Phone/Fax

Practice location:
  • Phone: 207-941-6550
  • Fax:
Mailing address:
  • Phone: 207-941-6550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDEN 4267
License Number StateME

VIII. Authorized Official

Name: DR. DAVID C HALUSKA
Title or Position: PRESIDENT
Credential: DMD
Phone: 207-249-9524