Healthcare Provider Details

I. General information

NPI: 1720444227
Provider Name (Legal Business Name): DENIS RUSSELL DAUPHINEE CSFA, LSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/13/2016
Last Update Date: 08/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 MAIN ST
BRADLEY ME
04411-5006
US

IV. Provider business mailing address

24 MAIN ST
BRADLEY ME
04411-5006
US

V. Phone/Fax

Practice location:
  • Phone: 207-817-3186
  • Fax:
Mailing address:
  • Phone: 207-817-3186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number149949
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: