Provider Demographics
NPI:1558605642
Name:MAINE CENTER FOR DENTAL MEDICINE PA
Entity Type:Organization
Organization Name:MAINE CENTER FOR DENTAL MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMMED
Authorized Official - Middle Name:MANSOORUL
Authorized Official - Last Name:IMAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:207-474-9503
Mailing Address - Street 1:59 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:SKOWHEGAN
Mailing Address - State:ME
Mailing Address - Zip Code:04976-1227
Mailing Address - Country:US
Mailing Address - Phone:207-474-9503
Mailing Address - Fax:207-474-5271
Practice Address - Street 1:59 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:SKOWHEGAN
Practice Address - State:ME
Practice Address - Zip Code:04976-1227
Practice Address - Country:US
Practice Address - Phone:207-474-9503
Practice Address - Fax:207-474-5271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2015-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN42311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty