Healthcare Provider Details

I. General information

NPI: 1649260936
Provider Name (Legal Business Name): LAURA ANN REIDY D.M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 PENN PLZ SUITE 32
BANGOR ME
04401-3620
US

IV. Provider business mailing address

20 PENN PLZ SUITE 32
BANGOR ME
04401-3620
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:
Title or Position:
Credential:
Phone: