MEDICARE: MADISON GENTLE FAMILY DENTISTRY LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1710799457
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MADISON GENTLE FAMILY DENTISTRY LLC

Provider Business Mailing Address
First Line	:	290 BRIDGTON RD STE 2
Second Line	:
City	:	WESTBROOK
State	:	ME
Zip	:	04092-3754
Country	:	US
Telephone Number	:	732-207-1689
Fax Number	:

Provider Business Practice Location Address
First Line	:	21 OLD POINT AVE
Second Line	:
City	:	MADISON
State	:	ME
Zip	:	04950-1114
Country	:	US
Telephone Number	:	207-696-4681
Fax Number	:	207-696-4275

Authorized Official
Title or Position	:	COO
Name	:	DAVID LEE
Credential	:
Telephone Number	:	732-207-1689

Provider Enumeration Date	:	01/21/2025
Last Update Date	:	01/21/2025

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