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General NPI Number Information
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NPI Number | 1598872103
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Entity Type | Organization
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Legal Business Name | ORTHODONTIC ASSOCIATES PA
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Dates
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Enumeration Date | 08/23/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 440 WESTERN AVE
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City | SOUTH PORTLAND
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State | ME
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Zip | 04106
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Country | US
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Telephone | 207-772-5487
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Fax | 207-772-7553
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Provider Business Mailing Address
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Address Line | 440 WESTERN AVE
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City | SOUTH PORTLAND
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State | ME
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Zip | 04106
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Country | US
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Telephone | 207-772-5487
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Fax | 207-772-7553
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Authorized Official
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Title or Position | DMD ABO
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Name | DR. BRUCE JAY PODHOUSER
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Credential | DMD ABO
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Telephone | 207-772-5487
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State | NH
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State | ME
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