Provider Demographics
NPI:1376999730
Name:CASTLEBERRY DENTAL
Entity Type:Organization
Organization Name:CASTLEBERRY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:C
Authorized Official - Last Name:CASTLEBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:207-374-5538
Mailing Address - Street 1:PO BOX 628
Mailing Address - Street 2:
Mailing Address - City:BLUE HILL
Mailing Address - State:ME
Mailing Address - Zip Code:04614
Mailing Address - Country:US
Mailing Address - Phone:207-374-5538
Mailing Address - Fax:207-374-2929
Practice Address - Street 1:120 SOUTH ST
Practice Address - Street 2:
Practice Address - City:BLUE HILL
Practice Address - State:ME
Practice Address - Zip Code:04614
Practice Address - Country:US
Practice Address - Phone:207-374-5538
Practice Address - Fax:207-374-2929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-04
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME42471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty