Healthcare Provider Details

I. General information

NPI: 1134032410
Provider Name (Legal Business Name): WOODLAND DENTAL AESTHETICS PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1389 BRIDGTON RD STE 2
WESTBROOK ME
04092-2573
US

IV. Provider business mailing address

205 PINECREST RD
PORTLAND ME
04102-1225
US

V. Phone/Fax

Practice location:
  • Phone: 207-464-2600
  • Fax: 207-464-2800
Mailing address:
  • Phone: 207-464-2600
  • Fax: 207-464-2800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. IVAN SOBERANES
Title or Position: DENTIST/OWNER
Credential: DMD
Phone: 207-464-2600