Provider Demographics
NPI:1003986589
Name:THEN, PETER RENE (DMD DR MED DENT)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:RENE
Last Name:THEN
Suffix:
Gender:M
Credentials:DMD DR MED DENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 VAILL POINT ROAD
Mailing Address - Street 2:
Mailing Address - City:YARMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04096
Mailing Address - Country:US
Mailing Address - Phone:207-846-3281
Mailing Address - Fax:
Practice Address - Street 1:254 WESTERN AVENUE
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106
Practice Address - Country:US
Practice Address - Phone:207-774-5527
Practice Address - Fax:207-780-1188
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME36281223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics