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General NPI Number Information
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NPI Number | 1689494213
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Entity Type | Organization
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Legal Business Name | COUNTY ROOTS CHILDRENS DENTISTRY LLC
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Dates
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Enumeration Date | 10/17/2024
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Last Update Date | 10/17/2024
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Provider Practice Location Address
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Address Line | 181 ACADEMY ST STE 4
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City | PRESQUE ISLE
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State | ME
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Zip | 04769-3178
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Country | US
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Telephone | 207-462-4767
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Fax | 207-512-1702
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Provider Business Mailing Address
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Address Line | P.O. BOX 4197
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City | PRESQUE ISLE
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State | ME
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Zip | 04769
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Country | US
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Telephone | 207-462-4767
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Fax | 207-512-1702
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Authorized Official
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Title or Position | PEDIATRIC DENTIST
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Name | DR. ERIK ARTHUR JOHNSON
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Credential | DMD
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Telephone | 207-551-3304
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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 |
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