Provider Demographics
NPI:1497250740
Name:NORTHEAST DENTAL PARTNERS, PA
Entity Type:Organization
Organization Name:NORTHEAST DENTAL PARTNERS, PA
Other - Org Name:NORTHEAST DENTAL PARTNERS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:CABRAL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:207-307-7405
Mailing Address - Street 1:181 NORFOLK ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3466
Mailing Address - Country:US
Mailing Address - Phone:860-328-0716
Mailing Address - Fax:207-307-7490
Practice Address - Street 1:24 DIRIGO DRIVE
Practice Address - Street 2:
Practice Address - City:BREWER
Practice Address - State:ME
Practice Address - Zip Code:04412
Practice Address - Country:US
Practice Address - Phone:207-307-7405
Practice Address - Fax:207-307-7490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-28
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME44921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty