Healthcare Provider Details

I. General information

NPI: 1295828069
Provider Name (Legal Business Name): SOUTHERN MAINE PERIODONTAL ASSOC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

276 CANCO RD
PORTLAND ME
04103
US

IV. Provider business mailing address

276 CANCO RD
PORTLAND ME
04103
US

V. Phone/Fax

Practice location:
  • Phone: 207-780-1822
  • Fax: 207-780-6022
Mailing address:
  • Phone: 207-780-1822
  • Fax: 207-780-6022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number3390
License Number StateME

VIII. Authorized Official

Name: DR. DENISE M THERIAULT
Title or Position: OWNER
Credential: DMD
Phone: 207-780-1922