Healthcare Provider Details

I. General information

NPI: 1952803587
Provider Name (Legal Business Name): JENNA MACDONALD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2018
Last Update Date: 02/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 PETTINGILL ST
LEWISTON ME
04240-5903
US

IV. Provider business mailing address

19 PETTINGILL ST
LEWISTON ME
04240-5903
US

V. Phone/Fax

Practice location:
  • Phone: 207-513-1111
  • Fax: 207-513-1197
Mailing address:
  • Phone: 207-513-1111
  • Fax: 207-513-1197

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberRDH3737
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: