Healthcare Provider Details

I. General information

NPI: 1417058504
Provider Name (Legal Business Name): GARY C. FERGUSON DMD, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 12/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

151 SILVER ST
WATERVILLE ME
04901-5813
US

IV. Provider business mailing address

151 SILVER ST
WATERVILLE ME
04901-5813
US

V. Phone/Fax

Practice location:
  • Phone: 207-873-1311
  • Fax: 207-873-4547
Mailing address:
  • Phone: 207-873-1311
  • Fax: 207-873-4547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number3442
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: