Healthcare Provider Details

I. General information

NPI: 1285854836
Provider Name (Legal Business Name): PENOBSCOT CHILDRENS DENTISTRY ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

792 STILLWATER AVE
BANGOR ME
04401-3617
US

IV. Provider business mailing address

792 STILLWATER AVE
BANGOR ME
04401-3617
US

V. Phone/Fax

Practice location:
  • Phone: 207-947-6733
  • Fax: 207-947-6760
Mailing address:
  • Phone: 207-947-6733
  • Fax: 207-947-6760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number3649
License Number StateME

VIII. Authorized Official

Name: DR. JONATHAN DAVID SHENKIN
Title or Position: PEDIATRIC DENTIST
Credential: DDS
Phone: 207-947-6733