Provider Demographics
NPI:1154446672
Name:COASTAL FAMILY DENTAL P.A.
Entity Type:Organization
Organization Name:COASTAL FAMILY DENTAL P.A.
Other - Org Name:ALAN J. CHEBUSKE D.M.D.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/BILLING ENTITY
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:JESSE
Authorized Official - Last Name:CHEBUSKE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:207-797-7433
Mailing Address - Street 1:110 AUBURN STREET
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103
Mailing Address - Country:US
Mailing Address - Phone:207-797-7433
Mailing Address - Fax:207-797-7720
Practice Address - Street 1:110 AUBURN STREET
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103
Practice Address - Country:US
Practice Address - Phone:207-797-7433
Practice Address - Fax:207-797-7720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME30471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME124010000Medicaid