Healthcare Provider Details

I. General information

NPI: 1124125380
Provider Name (Legal Business Name): ATLANTIC ORTHODONTIC CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 12/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 BRICKYARD LN
YORK ME
03909-1604
US

IV. Provider business mailing address

11 BRICKYARD LN
YORK ME
03909-1604
US

V. Phone/Fax

Practice location:
  • Phone: 207-363-7270
  • Fax:
Mailing address:
  • Phone: 207-363-7270
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number3676
License Number StateME

VIII. Authorized Official

Name: DR. TANYA GLIDDEN
Title or Position: OWNER
Credential: DMD,MS
Phone: 207-363-7270