Provider Demographics
NPI:1467528851
Name:COMMUNITY DENTAL
Entity Type:Organization
Organization Name:COMMUNITY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:IT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:PELKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-874-1025
Mailing Address - Street 1:190 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2910
Mailing Address - Country:US
Mailing Address - Phone:207-874-1028
Mailing Address - Fax:207-842-2963
Practice Address - Street 1:190 PARK AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2910
Practice Address - Country:US
Practice Address - Phone:207-874-1028
Practice Address - Fax:207-842-2963
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COMMUNITY DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME167870000Medicaid