Provider Demographics
NPI:1437362779
Name:PORTLAND FAMILY DENTAL
Entity Type:Organization
Organization Name:PORTLAND FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:SUNDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:207-797-3585
Mailing Address - Street 1:1006 FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-3343
Mailing Address - Country:US
Mailing Address - Phone:207-797-3585
Mailing Address - Fax:
Practice Address - Street 1:1006 FOREST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-3343
Practice Address - Country:US
Practice Address - Phone:207-797-3585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME3644122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty