Provider Demographics
NPI:1235896101
Name:RJ DENTAL PA
Entity Type:Organization
Organization Name:RJ DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:JEFFREY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:207-907-9247
Mailing Address - Street 1:15 GOLDSMITH LN
Mailing Address - Street 2:
Mailing Address - City:OLD TOWN
Mailing Address - State:ME
Mailing Address - Zip Code:04468-1489
Mailing Address - Country:US
Mailing Address - Phone:207-827-7179
Mailing Address - Fax:
Practice Address - Street 1:15 GOLDSMITH LN
Practice Address - Street 2:
Practice Address - City:OLD TOWN
Practice Address - State:ME
Practice Address - Zip Code:04468-1489
Practice Address - Country:US
Practice Address - Phone:207-827-7179
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-26
Last Update Date:2021-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental