Provider Demographics
NPI:1114155652
Name:VAUGHAN, DAVID A (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:VAUGHAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 FOREST AVE.
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-1889
Mailing Address - Country:US
Mailing Address - Phone:207-878-6693
Mailing Address - Fax:207-878-6678
Practice Address - Street 1:1250 FOREST AVE.
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-1889
Practice Address - Country:US
Practice Address - Phone:207-878-6693
Practice Address - Fax:207-878-6678
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME3160122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME198750000Medicaid