Provider Demographics
NPI:1417348053
Name:BEVINS, THERESA LOUISE (RDH)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:LOUISE
Last Name:BEVINS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 LEVESQUE DRIVE, SUITE 3
Mailing Address - Street 2:KINGSTON FAMILY DENTAL
Mailing Address - City:ELIOT
Mailing Address - State:ME
Mailing Address - Zip Code:03903
Mailing Address - Country:US
Mailing Address - Phone:207-439-0779
Mailing Address - Fax:
Practice Address - Street 1:17 LEVESQUE DRIVE, SUITE 3
Practice Address - Street 2:KINGSTON FAMILY DENTAL
Practice Address - City:ELIOT
Practice Address - State:ME
Practice Address - Zip Code:03903
Practice Address - Country:US
Practice Address - Phone:207-439-0779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-17
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH02448124Q00000X
ME2621124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist