Healthcare Provider Details

I. General information

NPI: 1629022611
Provider Name (Legal Business Name): 1330 DENTAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 CONGRESS STREET
PORTLAND ME
04102
US

IV. Provider business mailing address

1330 CONGRESS STREET
PORTLAND ME
04102
US

V. Phone/Fax

Practice location:
  • Phone: 207-773-3738
  • Fax: 207-773-5872
Mailing address:
  • Phone: 207-773-3738
  • Fax: 207-773-5872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2654
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number3251
License Number StateME
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number3533
License Number StateME
# 4
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number3693
License Number StateME
# 5
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3052
License Number StateME

VIII. Authorized Official

Name: DR. JAMES G BENNAS JR.
Title or Position: PRESIDENT
Credential: DMD
Phone: 207-773-3738