Provider Demographics
NPI:1003430711
Name:MD PORTLAND LLC
Entity Type:Organization
Organization Name:MD PORTLAND LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:LAWLOR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:207-307-1793
Mailing Address - Street 1:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:ME
Mailing Address - Zip Code:04039-0850
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 MIDDLE ST # A-C2
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4881
Practice Address - Country:US
Practice Address - Phone:207-307-1793
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LAWLOR ENTERPRISES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-05-29
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental