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General NPI Number Information
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NPI Number | 1396967824
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Entity Type | Organization
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Legal Business Name | NORTHEAST PERIODOANTAL ASSOCIATES
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Dates
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Enumeration Date | 05/03/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 20 PENN PLAZA, SUITE 32
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City | BANGOR
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State | ME
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Zip | 04401
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Country | US
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Telephone | 207-941-2300
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Fax | 207-941-9683
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Provider Business Mailing Address
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Address Line | 20 PENN PLAZA, SUITE 32
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City | BANGOR
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State | ME
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Zip | 04401
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Country | US
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Telephone | 207-941-2300
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Fax | 207-941-9683
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Authorized Official
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Title or Position | PERIODONTIST
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Name | DR. LAURA REIDY
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Credential | D.M.D.
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Telephone | 207-941-2300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 3092
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License Number State | ME
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