Healthcare Provider Details

I. General information

NPI: 1386401826
Provider Name (Legal Business Name): FOREST FALLS DENTAL HOLDING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2024
Last Update Date: 03/01/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 FOREST FALLS DR STOP 9
YARMOUTH ME
04096-4900
US

IV. Provider business mailing address

1290 CONGRESS ST
PORTLAND ME
04102-2113
US

V. Phone/Fax

Practice location:
  • Phone: 207-846-3966
  • Fax:
Mailing address:
  • Phone: 732-207-1689
  • Fax:

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: DAVID LEE
Title or Position: COO
Credential:
Phone: 732-207-1689