Provider Demographics
NPI:1366677965
Name:CARBONE, AUSTIN J (LD)
Entity Type:Individual
Prefix:
First Name:AUSTIN
Middle Name:J
Last Name:CARBONE
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 STILLWATER AVE
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3984
Mailing Address - Country:US
Mailing Address - Phone:207-941-6550
Mailing Address - Fax:
Practice Address - Street 1:12 STILLWATER AVE
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3984
Practice Address - Country:US
Practice Address - Phone:207-941-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-27
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME5001122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432762299Medicaid