Healthcare Provider Details

I. General information

NPI: 1053632901
Provider Name (Legal Business Name): DASHIELL JORDAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: DASHIELL J SLABBERT MD

II. Dates (important events)

Enumeration Date: 06/15/2010
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 CAMPUS AVE STE 201
LEWISTON ME
04240-6045
US

IV. Provider business mailing address

PO BOX 1638
ALBANY NY
12201-1638
US

V. Phone/Fax

Practice location:
  • Phone: 207-777-8810
  • Fax: 207-777-8155
Mailing address:
  • Phone: 207-777-4111
  • Fax: 207-783-6660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTD171104
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: