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General NPI Number Information
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NPI Number | 1811575202
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Entity Type | Organization
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Legal Business Name | BREAKWATER DENTAL, LLC
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Dates
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Enumeration Date | 03/29/2021
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Last Update Date | 03/29/2021
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Provider Practice Location Address
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Address Line | 25 LONG CREEK DR UNIT D
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City | SOUTH PORTLAND
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State | ME
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Zip | 04106-2440
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Country | US
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Telephone | 207-775-2072
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Fax |
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Provider Business Mailing Address
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Address Line | 5 MIDNIGHT LN
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City | GORHAM
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State | ME
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Zip | 04038-2376
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Country | US
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Telephone | 207-272-9847
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Fax |
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. SHILO ANNIS
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Credential | DMD
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Telephone | 207-272-9847
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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