Provider Demographics
NPI:1073363677
Name:MAINE PEDIATRIC DENTISTRY LLC
Entity Type:Organization
Organization Name:MAINE PEDIATRIC DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-207-1689
Mailing Address - Street 1:290 BRIDGTON RD STE 2
Mailing Address - Street 2:
Mailing Address - City:WESTBROOK
Mailing Address - State:ME
Mailing Address - Zip Code:04092-3754
Mailing Address - Country:US
Mailing Address - Phone:732-207-1689
Mailing Address - Fax:
Practice Address - Street 1:85 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2423
Practice Address - Country:US
Practice Address - Phone:207-408-0479
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-26
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty