=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205378569
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DANDY DENTURES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2016
-----------------------------------------------------
Last Update Date | 11/17/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3 BRIGHAM ST
-----------------------------------------------------
City | WATERVILLE
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04901-5114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-877-9917
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 BRIGHAM ST
-----------------------------------------------------
City | WATERVILLE
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04901-5114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-877-9917
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PATRICK D ALLEN
-----------------------------------------------------
Credential | LD
-----------------------------------------------------
Telephone | 207-877-9917
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122400000X
-----------------------------------------------------
Taxonomy Name | Denturist
-----------------------------------------------------
License Number | 5512
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------