Healthcare Provider Details

I. General information

NPI: 1881209641
Provider Name (Legal Business Name): CANDID MAINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 09/09/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 CONGRESS ST STE 201
PORTLAND ME
04101-3500
US

IV. Provider business mailing address

44 W 28TH ST FL 14
NEW YORK NY
10001-4212
US

V. Phone/Fax

Practice location:
  • Phone: 860-481-7631
  • Fax:
Mailing address:
  • Phone: 860-481-7631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. RICHARD D'AVANZO
Title or Position: OWNER
Credential: DMD
Phone: 860-481-7631