Healthcare Provider Details

I. General information

NPI: 1861611949
Provider Name (Legal Business Name): ENDODONTIC ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82 COYLE STREET
PORTLAND ME
04101
US

IV. Provider business mailing address

82 COYLE STREET
PORTLAND ME
04101-4351
US

V. Phone/Fax

Practice location:
  • Phone: 207-772-7431
  • Fax:
Mailing address:
  • Phone: 207-772-7431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number StateME

VIII. Authorized Official

Name: MRS. LISA CHAPPEL
Title or Position: OFFICE COORDINATOR
Credential:
Phone: 207-772-7431