Healthcare Provider Details

I. General information

NPI: 1124327564
Provider Name (Legal Business Name): RANDAL JOSEPH THIVIERGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2011
Last Update Date: 11/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 ROCKLAND ST
ROCKPORT ME
04856-5320
US

IV. Provider business mailing address

625 ROCKLAND ST
ROCKPORT ME
04856-5320
US

V. Phone/Fax

Practice location:
  • Phone: 207-236-3100
  • Fax: 207-236-8380
Mailing address:
  • Phone: 207-236-3100
  • Fax: 207-236-8380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number3037
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3037
License Number StateME

VIII. Authorized Official

Name: MS. JODY L LAVOIE
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 207-236-3100