Healthcare Provider Details

I. General information

NPI: 1346340692
Provider Name (Legal Business Name): JAY MORGAN KNUDSEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 MAIN STREET SUITE 1
SPRINGVALE ME
04083
US

IV. Provider business mailing address

460 MAIN STREET SUITE 1
SPRINGVALE ME
04083
US

V. Phone/Fax

Practice location:
  • Phone: 207-324-6182
  • Fax: 207-324-4336
Mailing address:
  • Phone: 207-324-6182
  • Fax: 207-324-4336

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3773
License Number StateME

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: