Healthcare Provider Details

I. General information

NPI: 1568909455
Provider Name (Legal Business Name): PAUL J GUALTIERI D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2017
Last Update Date: 04/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 BROADWAY
BUCKSPORT ME
04416-4612
US

IV. Provider business mailing address

110 BROADWAY
BUCKSPORT ME
04416-4612
US

V. Phone/Fax

Practice location:
  • Phone: 207-469-7371
  • Fax: 207-469-7306
Mailing address:
  • Phone: 207-469-7371
  • Fax: 207-469-7306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number000000
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: