Healthcare Provider Details

I. General information

NPI: 1063729002
Provider Name (Legal Business Name): GARY LEE CREISHER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2010
Last Update Date: 09/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 YORK ST
KENNEBUNK ME
04043-7152
US

IV. Provider business mailing address

31 YORK ST
KENNEBUNK ME
04043-7152
US

V. Phone/Fax

Practice location:
  • Phone: 207-985-2800
  • Fax: 207-985-7185
Mailing address:
  • Phone: 207-985-2800
  • Fax: 207-985-7185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDEN3715
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: