=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245619097
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROSKELLEY DENTAL, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2015
-----------------------------------------------------
Last Update Date | 05/27/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 323 MAIN ST
-----------------------------------------------------
City | SACO
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04072-1514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-282-9962
-----------------------------------------------------
Fax | 207-283-4299
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 323 MAIN ST
-----------------------------------------------------
City | SACO
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04072-1514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-282-9962
-----------------------------------------------------
Fax | 207-283-4299
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | JACOB ROSKELLEY
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 207-282-9962
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 4279
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------