Healthcare Provider Details

I. General information

NPI: 1881814788
Provider Name (Legal Business Name): DAVID A. THERIAULT, D.M.D
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 SUMMER ST
ROCKLAND ME
04841-2917
US

IV. Provider business mailing address

19 SUMMER ST
ROCKLAND ME
04841-2917
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3298
License Number StateME

VIII. Authorized Official

Name: LINDSAY HARVEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 207-594-8353