Provider Demographics
NPI:1164206553
Name:WATERBORO DENTISTRY
Entity Type:Organization
Organization Name:WATERBORO DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LARIVIERE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-247-3511
Mailing Address - Street 1:PO BOX 378
Mailing Address - Street 2:
Mailing Address - City:WATERBORO
Mailing Address - State:ME
Mailing Address - Zip Code:04087-0378
Mailing Address - Country:US
Mailing Address - Phone:207-247-3511
Mailing Address - Fax:
Practice Address - Street 1:813B MAIN ST
Practice Address - Street 2:
Practice Address - City:WATERBORO
Practice Address - State:ME
Practice Address - Zip Code:04087-3084
Practice Address - Country:US
Practice Address - Phone:207-247-3511
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEDEN4703OtherDENTAL LICENSE
MEME2821OtherDENTAL LICENSE