Provider Demographics
NPI:1295828069
Name:SOUTHERN MAINE PERIODONTAL ASSOC PA
Entity Type:Organization
Organization Name:SOUTHERN MAINE PERIODONTAL ASSOC PA
Other - Org Name:DENISE M THERIAULT DMD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:M
Authorized Official - Last Name:THERIAULT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:207-780-1922
Mailing Address - Street 1:276 CANCO RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103
Mailing Address - Country:US
Mailing Address - Phone:207-780-1822
Mailing Address - Fax:207-780-6022
Practice Address - Street 1:276 CANCO RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103
Practice Address - Country:US
Practice Address - Phone:207-780-1822
Practice Address - Fax:207-780-6022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME33901223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty