Provider Demographics
NPI:1568670347
Name:JACQUELINE TJON SIEUW MORIN
Entity Type:Organization
Organization Name:JACQUELINE TJON SIEUW MORIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:TJON SIEUW MORIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:207-474-9326
Mailing Address - Street 1:28 S FACTORY ST
Mailing Address - Street 2:
Mailing Address - City:SKOWHEGAN
Mailing Address - State:ME
Mailing Address - Zip Code:04976-1425
Mailing Address - Country:US
Mailing Address - Phone:207-474-9326
Mailing Address - Fax:
Practice Address - Street 1:28 S FACTORY ST
Practice Address - Street 2:
Practice Address - City:SKOWHEGAN
Practice Address - State:ME
Practice Address - Zip Code:04976-1425
Practice Address - Country:US
Practice Address - Phone:207-474-9326
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME3429122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty