Provider Demographics
NPI:1376878199
Name:WESTERN MAINE DENTISTRY, PA
Entity Type:Organization
Organization Name:WESTERN MAINE DENTISTRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:TYLER
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:207-743-2649
Mailing Address - Street 1:193 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORWAY
Mailing Address - State:ME
Mailing Address - Zip Code:04268-5645
Mailing Address - Country:US
Mailing Address - Phone:207-743-2649
Mailing Address - Fax:207-743-0432
Practice Address - Street 1:193 MAIN ST
Practice Address - Street 2:
Practice Address - City:NORWAY
Practice Address - State:ME
Practice Address - Zip Code:04268-5645
Practice Address - Country:US
Practice Address - Phone:207-743-2649
Practice Address - Fax:207-743-0432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-13
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN29831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME118930000Medicaid