Provider Demographics
NPI:1154867109
Name:FRYEBURG DENTAL CENTER LLC
Entity Type:Organization
Organization Name:FRYEBURG DENTAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:B
Authorized Official - Last Name:HARPER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:207-935-3133
Mailing Address - Street 1:44 PORTLAND ST
Mailing Address - Street 2:
Mailing Address - City:FRYEBURG
Mailing Address - State:ME
Mailing Address - Zip Code:04037-1206
Mailing Address - Country:US
Mailing Address - Phone:207-935-3133
Mailing Address - Fax:
Practice Address - Street 1:44 PORTLAND ST
Practice Address - Street 2:
Practice Address - City:FRYEBURG
Practice Address - State:ME
Practice Address - Zip Code:04037-1206
Practice Address - Country:US
Practice Address - Phone:207-935-3133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-15
Last Update Date:2017-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN4507122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty