Healthcare Provider Details

I. General information

NPI: 1053330910
Provider Name (Legal Business Name): DAVID ARTHUR THERIAULT DHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 SUMMER STREET
ROCKLAND ME
04841
US

IV. Provider business mailing address

19 SUMMER STREET
ROCKLAND ME
04841
US

V. Phone/Fax

Practice location:
  • Phone: 207-594-8353
  • Fax: 207-594-8306
Mailing address:
  • Phone: 207-594-8353
  • Fax: 207-594-8306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3298MAINE
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: