Healthcare Provider Details

I. General information

NPI: 1922723543
Provider Name (Legal Business Name): JETPORT DENTURE CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2022
Last Update Date: 10/06/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 FOREST AVE STE 104
PORTLAND ME
04103-3357
US

IV. Provider business mailing address

980 FOREST AVE STE 104
PORTLAND ME
04103-3357
US

V. Phone/Fax

Practice location:
  • Phone: 207-774-7645
  • Fax: 207-828-5298
Mailing address:
  • Phone: 207-774-7645
  • Fax: 207-828-5298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License Number
License Number State

VIII. Authorized Official

Name: MR. AUSTIN CARBONE
Title or Position: OWNER
Credential: LD
Phone: 207-774-7645