Provider Demographics
NPI:1407029184
Name:COSMETIC & GENERAL DENTISTRY OF WINTHROP
Entity Type:Organization
Organization Name:COSMETIC & GENERAL DENTISTRY OF WINTHROP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:R
Authorized Official - Last Name:WIETECHA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:207-377-6958
Mailing Address - Street 1:28 OLD WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:ME
Mailing Address - Zip Code:04364-4060
Mailing Address - Country:US
Mailing Address - Phone:207-377-6958
Mailing Address - Fax:207-377-4349
Practice Address - Street 1:28 OLD WESTERN AVE
Practice Address - Street 2:
Practice Address - City:WINTHROP
Practice Address - State:ME
Practice Address - Zip Code:04364-4060
Practice Address - Country:US
Practice Address - Phone:207-377-6958
Practice Address - Fax:207-377-4349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-02
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME3627261QD0000X
ME2556261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental