Healthcare Provider Details

I. General information

NPI: 1710061494
Provider Name (Legal Business Name): MAINE DERMATOLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 06/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2239 ATLANTIC HWY
LINCOLNVILLE ME
04849-5310
US

IV. Provider business mailing address

2239 ATLANTIC HWY
LINCOLNVILLE ME
04849-5310
US

V. Phone/Fax

Practice location:
  • Phone: 207-230-1007
  • Fax: 207-230-1008
Mailing address:
  • Phone: 207-230-1007
  • Fax: 207-230-1008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number1822
License Number StateME

VIII. Authorized Official

Name: CHARMAINE JENSEN
Title or Position: OWNER/ DOCTOR
Credential: D.O.
Phone: 207-230-1007