Healthcare Provider Details

I. General information

NPI: 1861204513
Provider Name (Legal Business Name): PORTLAND CENTER FOR DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2025
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 BRIGHTON AVE STE 1
PORTLAND ME
04102-2359
US

IV. Provider business mailing address

290 BRIDGTON RD STE 2
WESTBROOK ME
04092-3754
US

V. Phone/Fax

Practice location:
  • Phone: 207-560-9057
  • Fax:
Mailing address:
  • Phone: 732-207-1689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DAVID LEE
Title or Position: COO
Credential:
Phone: 732-207-1689