Healthcare Provider Details

I. General information

NPI: 1225285539
Provider Name (Legal Business Name): MICHAEL KENNETH STEWART FIRTH L.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2008
Last Update Date: 08/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1364 MAIN ST SUITE 13, BOX 15
SANFORD ME
04073-3660
US

IV. Provider business mailing address

1364 MAIN STREET SUITE 13, BOX 15
SANFORD ME
04073-3660
US

V. Phone/Fax

Practice location:
  • Phone: 207-324-4611
  • Fax: 207-324-4628
Mailing address:
  • Phone: 207-324-4611
  • Fax: 207-324-4628

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License Number5505
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: