Healthcare Provider Details

I. General information

NPI: 1801560842
Provider Name (Legal Business Name): ASHLEY DAWN SOUCY LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ASHLEY DAWN LIBBY

II. Dates (important events)

Enumeration Date: 08/03/2021
Last Update Date: 08/03/2021
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 FOREST AVE STE 104
PORTLAND ME
04103-3357
US

IV. Provider business mailing address

57 NOWELL ST
NORTH BERWICK ME
03906-6519
US

V. Phone/Fax

Practice location:
  • Phone: 207-774-7645
  • Fax:
Mailing address:
  • Phone: 207-794-5322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberDTR5539
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: