MEDICARE: DENTAL SPECIALISTS OF PORTLAND

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	1223E0200X	Endodontics	3810	ME

General Provider Information

NPI Number	:	1780868687
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTAL SPECIALISTS OF PORTLAND

Provider Business Mailing Address
First Line	:	1355 CONGRESS ST
Second Line	:	SUITE A
City	:	PORTLAND
State	:	ME
Zip	:	04102-2160
Country	:	US
Telephone Number	:	207-879-0010
Fax Number	:	207-879-0011

Provider Business Practice Location Address
First Line	:	1355 CONGRESS ST
Second Line	:	SUITE A
City	:	PORTLAND
State	:	ME
Zip	:	04102-2160
Country	:	US
Telephone Number	:	207-879-0010
Fax Number	:	207-879-0011

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	MISS MARCIE PAULINE PHILLIPS
Credential	:
Telephone Number	:	207-879-0010

Provider Enumeration Date	:	12/27/2007
Last Update Date	:	12/27/2007

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Directions to “DENTAL SPECIALISTS OF PORTLAND ” Practice Location

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