Healthcare Provider Details

I. General information

NPI: 1629497912
Provider Name (Legal Business Name): FOREST FALLS DENTAL, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2014
Last Update Date: 04/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 FOREST FALLS DR UNIT 9A
YARMOUTH ME
04096-6936
US

IV. Provider business mailing address

10 FOREST FALLS DR UNIT 9A
YARMOUTH ME
04096-6936
US

V. Phone/Fax

Practice location:
  • Phone: 207-846-3966
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4101
License Number StateME

VIII. Authorized Official

Name: EUGENE KIM
Title or Position: OWNER
Credential: DDS
Phone: 207-846-3966