Healthcare Provider Details

I. General information

NPI: 1316628811
Provider Name (Legal Business Name): VIRGINIA EDELMIRA PYBURN IPDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2023
Last Update Date: 07/27/2023
Certification Date: 07/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 SULLIVAN ST
BERWICK ME
03901-2925
US

IV. Provider business mailing address

4 WOODLAND AVE
SEABROOK NH
03874-4524
US

V. Phone/Fax

Practice location:
  • Phone: 207-810-6019
  • Fax:
Mailing address:
  • Phone: 603-918-9490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberRDH4486
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: