Provider Demographics
NPI:1255474698
Name:NORTHEAST ORAL & MAXILLOFACIAL SURGERY ASSOCIATES P.A.
Entity Type:Organization
Organization Name:NORTHEAST ORAL & MAXILLOFACIAL SURGERY ASSOCIATES P.A.
Other - Org Name:NORTHEAST ORAL & MAXILLOFACIAL SURGERY P.A.(REMOVE)
Other - Org Type:Other Name
Authorized Official - Title/Position:CO-OWNER/SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:DEIGHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:207-945-5691
Mailing Address - Street 1:37 BOWER ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4721
Mailing Address - Country:US
Mailing Address - Phone:207-945-5691
Mailing Address - Fax:207-942-9525
Practice Address - Street 1:37 BOWER ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4721
Practice Address - Country:US
Practice Address - Phone:207-945-5691
Practice Address - Fax:207-942-9525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME30791223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME246780099Medicaid
MET31315Medicare UPIN
MEMM0471Medicare PIN