Healthcare Provider Details

I. General information

NPI: 1255474698
Provider Name (Legal Business Name): NORTHEAST ORAL & MAXILLOFACIAL SURGERY ASSOCIATES P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 12/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37 BOWER ST
BANGOR ME
04401-4721
US

IV. Provider business mailing address

37 BOWER ST
BANGOR ME
04401-4721
US

V. Phone/Fax

Practice location:
  • Phone: 207-945-5691
  • Fax: 207-942-9525
Mailing address:
  • Phone: 207-945-5691
  • Fax: 207-942-9525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number3079
License Number StateME

VIII. Authorized Official

Name: DR. WILLIAM A. DEIGHAN
Title or Position: CO-OWNER/SURGEON
Credential: D.M.D.
Phone: 207-945-5691