Healthcare Provider Details

I. General information

NPI: 1376999730
Provider Name (Legal Business Name): CASTLEBERRY DENTAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2016
Last Update Date: 02/26/2025
Certification Date: 02/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

382 STATE ST
ELLSWORTH ME
04605-3330
US

IV. Provider business mailing address

PO BOX 29
ELLSWORTH ME
04605-0029
US

V. Phone/Fax

Practice location:
  • Phone: 207-374-5538
  • Fax: 207-613-2424
Mailing address:
  • Phone: 207-374-5538
  • Fax: 207-613-2424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. TRAVIS C CASTLEBERRY
Title or Position: OWNER
Credential: DMD
Phone: 207-374-5538