Provider Demographics
NPI:1285854836
Name:PENOBSCOT CHILDRENS DENTISTRY ASSOCIATES
Entity Type:Organization
Organization Name:PENOBSCOT CHILDRENS DENTISTRY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:SHENKIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:207-947-6733
Mailing Address - Street 1:792 STILLWATER AVE
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3617
Mailing Address - Country:US
Mailing Address - Phone:207-947-6733
Mailing Address - Fax:207-947-6760
Practice Address - Street 1:792 STILLWATER AVE
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3617
Practice Address - Country:US
Practice Address - Phone:207-947-6733
Practice Address - Fax:207-947-6760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME36491223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTAX ID NUMBER