Healthcare Provider Details

I. General information

NPI: 1932329943
Provider Name (Legal Business Name): PERIODONTAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 BRIGHTON AVE
PORTLAND ME
04102-2359
US

IV. Provider business mailing address

612 BRIGHTON AVE
PORTLAND ME
04102-2359
US

V. Phone/Fax

Practice location:
  • Phone: 207-772-7459
  • Fax: 207-874-6460
Mailing address:
  • Phone: 207-772-7459
  • Fax: 207-874-6460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2204
License Number StateME

VIII. Authorized Official

Name: GEORGE D GORDON
Title or Position: PRESIDENT
Credential: DMD
Phone: 207-772-7459