Provider Demographics
NPI:1174184253
Name:GORHAM VILLAGE DENTAL LLC
Entity Type:Organization
Organization Name:GORHAM VILLAGE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CORY
Authorized Official - Middle Name:
Authorized Official - Last Name:MURRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:207-642-4300
Mailing Address - Street 1:77 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04038-1715
Mailing Address - Country:US
Mailing Address - Phone:207-642-4300
Mailing Address - Fax:
Practice Address - Street 1:77 SOUTH ST
Practice Address - Street 2:
Practice Address - City:GORHAM
Practice Address - State:ME
Practice Address - Zip Code:04038-1715
Practice Address - Country:US
Practice Address - Phone:207-642-4300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-27
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental