Healthcare Provider Details

I. General information

NPI: 1144330432
Provider Name (Legal Business Name): DIMEREZE MARY CLARK RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 SAINT ANDREWS LN
BOOTHBAY HARBOR ME
04538-1731
US

IV. Provider business mailing address

7 WILDERNESSS DR
BOOTHBAY ME
04537-5022
US

V. Phone/Fax

Practice location:
  • Phone: 207-633-2121
  • Fax: 207-633-1276
Mailing address:
  • Phone: 207-633-3780
  • Fax: 207-633-1276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD14
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: