Healthcare Provider Details

I. General information

NPI: 1093781254
Provider Name (Legal Business Name): MICHAEL A DEDEKIAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 01/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

887 CONGRESS ST SUITE 320
PORTLAND ME
04102
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 207-662-5522
  • Fax: 207-662-5527
Mailing address:
  • Phone: 207-396-8600
  • Fax: 207-396-8632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number224852
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number017981
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: