Healthcare Provider Details

I. General information

NPI: 1700015526
Provider Name (Legal Business Name): JOSEPH S KINGSTON ED.D; LD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2009
Last Update Date: 07/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 HERSEY AVE
BANGOR ME
04401-4443
US

IV. Provider business mailing address

61 HERSEY AVE
BANGOR ME
04401-4443
US

V. Phone/Fax

Practice location:
  • Phone: 207-942-1743
  • Fax:
Mailing address:
  • Phone: 207-942-1743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License Number5515
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: