Healthcare Provider Details

I. General information

NPI: 1144741570
Provider Name (Legal Business Name): WYATT JOHN TRAINA D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2017
Last Update Date: 07/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 JOHNSON RD STE 4
PORTLAND ME
04102-1988
US

IV. Provider business mailing address

43 NEWTON ST
PORTLAND ME
04103-1523
US

V. Phone/Fax

Practice location:
  • Phone: 207-775-6348
  • Fax:
Mailing address:
  • Phone: 207-380-4671
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDEN4410
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: