Provider Demographics
NPI:1114153939
Name:KENNEBEC VALLEY FAMILY DENTISTRY
Entity Type:Organization
Organization Name:KENNEBEC VALLEY FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KIMBERLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-623-3400
Mailing Address - Street 1:6 E CHESTNUT ST STE 420
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330-5743
Mailing Address - Country:US
Mailing Address - Phone:207-623-3400
Mailing Address - Fax:207-623-3440
Practice Address - Street 1:269 WATER ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330-4645
Practice Address - Country:US
Practice Address - Phone:207-623-3400
Practice Address - Fax:207-623-3440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-08
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME3095305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service