Healthcare Provider Details

I. General information

NPI: 1629724877
Provider Name (Legal Business Name): 207 PERIODONTICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2022
Last Update Date: 02/25/2022
Certification Date: 02/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

595 BRIGHTON AVE
PORTLAND ME
04102-2322
US

IV. Provider business mailing address

595 BRIGHTON AVE
PORTLAND ME
04102-2322
US

V. Phone/Fax

Practice location:
  • Phone: 207-774-1471
  • Fax: 207-774-1472
Mailing address:
  • Phone: 207-774-1471
  • Fax: 207-774-1472

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: KARA ACHILLE
Title or Position: OWNER DENTIST
Credential: DMD
Phone: 207-774-1471