Healthcare Provider Details

I. General information

NPI: 1407426307
Provider Name (Legal Business Name): RIDEOUT PREVENTATIVE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2021
Last Update Date: 07/01/2021
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

859 W MAIN ST
DOVER FOXCROFT ME
04426-1020
US

IV. Provider business mailing address

152 GROVE ST
DOVER FOXCROFT ME
04426-1254
US

V. Phone/Fax

Practice location:
  • Phone: 207-876-6988
  • Fax:
Mailing address:
  • Phone: 207-876-6988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY RIDEOUT
Title or Position: OWNER
Credential: RDH
Phone: 207-876-6988