Provider Demographics
NPI:1568779957
Name:ST JOHN VALLEY DENTAL CENTER
Entity Type:Organization
Organization Name:ST JOHN VALLEY DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:NELSON
Authorized Official - Middle Name:
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:207-728-7557
Mailing Address - Street 1:309 SAINT THOMAS ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MADAWASKA
Mailing Address - State:ME
Mailing Address - Zip Code:04756-1278
Mailing Address - Country:US
Mailing Address - Phone:207-728-7557
Mailing Address - Fax:207-728-7558
Practice Address - Street 1:309 SAINT THOMAS ST
Practice Address - Street 2:SUITE 103
Practice Address - City:MADAWASKA
Practice Address - State:ME
Practice Address - Zip Code:04756-1278
Practice Address - Country:US
Practice Address - Phone:207-728-7557
Practice Address - Fax:207-728-7558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-07
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME3474122300000X
ME3697122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty