Healthcare Provider Details

I. General information

NPI: 1831256338
Provider Name (Legal Business Name): SOUTHERN MAINE ORAL AND MAXILLOFACIAL SURGERY PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 WESTERN AVENUE
SOUTH PORTLAND ME
04106
US

IV. Provider business mailing address

440 WESTERN AVENUE
SOUTH PORTLAND ME
04106
US

V. Phone/Fax

Practice location:
  • Phone: 207-774-2611
  • Fax: 207-774-2613
Mailing address:
  • Phone: 207-774-2611
  • Fax: 207-774-2613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. RICHARD W CRAWFORD
Title or Position: OWNER
Credential: DMD
Phone: 207-774-2611