Healthcare Provider Details

I. General information

NPI: 1396967824
Provider Name (Legal Business Name): NORTHEAST PERIODOANTAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 PENN PLAZA, SUITE 32
BANGOR ME
04401
US

IV. Provider business mailing address

20 PENN PLAZA, SUITE 32
BANGOR ME
04401
US

V. Phone/Fax

Practice location:
  • Phone: 207-941-2300
  • Fax: 207-941-9683
Mailing address:
  • Phone: 207-941-2300
  • Fax: 207-941-9683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number3092
License Number StateME

VIII. Authorized Official

Name: DR. LAURA REIDY
Title or Position: PERIODONTIST
Credential: D.M.D.
Phone: 207-941-2300