Healthcare Provider Details

I. General information

NPI: 1376774828
Provider Name (Legal Business Name): TOOTH FAIRIES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2009
Last Update Date: 07/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 LAFRINEA LN
POLAND ME
04274-6158
US

IV. Provider business mailing address

12 LAFRINEA LN
POLAND ME
04274-6158
US

V. Phone/Fax

Practice location:
  • Phone: 207-998-3500
  • Fax:
Mailing address:
  • Phone: 207-998-3500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License NumberRDH2546
License Number StateME

VIII. Authorized Official

Name: MRS. DOROTHY MARGARET MAROON
Title or Position: DENTAL HYGIENIST
Credential: RDH
Phone: 207-998-3500