Healthcare Provider Details

I. General information

NPI: 1376872622
Provider Name (Legal Business Name): TANYA GLIDDEN DMD, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2009
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:
Title or Position:
Credential:
Phone: