Provider Demographics
NPI:1528181229
Name:ISLAND COMMUNITY MEDICAL SERVICES - DENTAL
Entity Type:Organization
Organization Name:ISLAND COMMUNITY MEDICAL SERVICES - DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DINAH
Authorized Official - Middle Name:
Authorized Official - Last Name:MOYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-863-4109
Mailing Address - Street 1:PO BOX 1328
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04211-1328
Mailing Address - Country:US
Mailing Address - Phone:207-784-9185
Mailing Address - Fax:207-784-1594
Practice Address - Street 1:15 MEDICAL CENTER LOOP
Practice Address - Street 2:
Practice Address - City:VINALHAVEN
Practice Address - State:ME
Practice Address - Zip Code:04863
Practice Address - Country:US
Practice Address - Phone:207-863-4341
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty