Healthcare Provider Details

I. General information

NPI: 1396026803
Provider Name (Legal Business Name): SEBASTICOOK FAMILY DOCTORS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2011
Last Update Date: 09/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

453 MAIN ST
PITTSFIELD ME
04967-5310
US

IV. Provider business mailing address

118 MOOSEHEAD TRL STE 5
NEWPORT ME
04953-4055
US

V. Phone/Fax

Practice location:
  • Phone: 207-355-3505
  • Fax: 207-474-8899
Mailing address:
  • Phone: 207-355-3505
  • Fax: 207-474-8899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: ROBIN L WINSLOW
Title or Position: CEO
Credential:
Phone: 207-368-5189