Provider Demographics
NPI:1184814568
Name:SOUTHERN MAINE PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:SOUTHERN MAINE PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:WHITNEY
Authorized Official - Middle Name:RALSTON
Authorized Official - Last Name:WIGNALL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:207-773-3111
Mailing Address - Street 1:75 JOHN ROBERTS RD
Mailing Address - Street 2:SUIT 10B
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6914
Mailing Address - Country:US
Mailing Address - Phone:207-773-3111
Mailing Address - Fax:
Practice Address - Street 1:75 JOHN ROBERTS RD
Practice Address - Street 2:SUIT 10B
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-6914
Practice Address - Country:US
Practice Address - Phone:207-773-3111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-31
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME3767261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental