Healthcare Provider Details

I. General information

NPI: 1568779957
Provider Name (Legal Business Name): ST JOHN VALLEY DENTAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2010
Last Update Date: 09/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 SAINT THOMAS ST SUITE 103
MADAWASKA ME
04756-1278
US

IV. Provider business mailing address

309 SAINT THOMAS ST SUITE 103
MADAWASKA ME
04756-1278
US

V. Phone/Fax

Practice location:
  • Phone: 207-728-7557
  • Fax: 207-728-7558
Mailing address:
  • Phone: 207-728-7557
  • Fax: 207-728-7558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number3697
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3474
License Number StateME

VIII. Authorized Official

Name: NELSON HENRY
Title or Position: DENTIST
Credential: DMD
Phone: 207-728-7557