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General NPI Number Information
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NPI Number | 1073363677
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Entity Type | Organization
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Legal Business Name | MAINE PEDIATRIC DENTISTRY LLC
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Dates
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Enumeration Date | 03/26/2024
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Last Update Date | 03/26/2024
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Provider Practice Location Address
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Address Line | 85 WESTERN AVE
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City | SOUTH PORTLAND
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State | ME
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Zip | 04106-2423
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Country | US
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Telephone | 207-408-0479
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Fax |
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Provider Business Mailing Address
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Address Line | 290 BRIDGTON RD STE 2
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City | WESTBROOK
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State | ME
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Zip | 04092-3754
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Country | US
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Telephone | 732-207-1689
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Fax |
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Authorized Official
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Title or Position | COO
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Name | DAVID LEE
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Credential |
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Telephone | 732-207-1689
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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