Healthcare Provider Details

I. General information

NPI: 1073702288
Provider Name (Legal Business Name): MAINEHEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2007
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 BRAMHALL ST
PORTLAND ME
04102-3134
US

IV. Provider business mailing address

301 US ROUTE 1 BUILDING C
SCARBOROUGH ME
04074-7609
US

V. Phone/Fax

Practice location:
  • Phone: 207-871-4078
  • Fax:
Mailing address:
  • Phone: 207-396-8600
  • Fax: 207-396-8632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: LUGENE ANTHONY INZANA
Title or Position: ASSOCIATE CFO
Credential:
Phone: 207-662-3538