Healthcare Provider Details

I. General information

NPI: 1770831224
Provider Name (Legal Business Name): GORHAM FAMILY AND COSMETIC DENTISTRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2012
Last Update Date: 08/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

347 MAIN ST
GORHAM ME
04038-1338
US

IV. Provider business mailing address

347 MAIN ST
GORHAM ME
04038-1338
US

V. Phone/Fax

Practice location:
  • Phone: 207-839-3006
  • Fax: 207-839-4593
Mailing address:
  • Phone: 207-839-3006
  • Fax: 207-839-4593

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4251
License Number StateNY

VIII. Authorized Official

Name: DR. CHRISTOPHER W PIDHAJECKY
Title or Position: OWNER
Credential: GENERAL DENTIST
Phone: 207-839-3006