Provider Demographics
NPI:1124561493
Name:CORNISH DENTURE CENTER, LLC
Entity Type:Organization
Organization Name:CORNISH DENTURE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:LAURETTE
Authorized Official - Last Name:SOULIERE
Authorized Official - Suffix:
Authorized Official - Credentials:LD
Authorized Official - Phone:207-625-9227
Mailing Address - Street 1:202 MAPLE ST UNIT C
Mailing Address - Street 2:
Mailing Address - City:CORNISH
Mailing Address - State:ME
Mailing Address - Zip Code:04020-3138
Mailing Address - Country:US
Mailing Address - Phone:207-625-9227
Mailing Address - Fax:
Practice Address - Street 1:202 MAPLE ST UNIT C
Practice Address - Street 2:
Practice Address - City:CORNISH
Practice Address - State:ME
Practice Address - Zip Code:04020-3138
Practice Address - Country:US
Practice Address - Phone:207-625-9227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-18
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDTR5531292200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes292200000XLaboratoriesDental Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEDTR5531Other122400000X