Provider Demographics
NPI:1598042640
Name:FREDERICK R MOLANDER, DMD, PA
Entity Type:Organization
Organization Name:FREDERICK R MOLANDER, DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:R
Authorized Official - Last Name:MOLANDER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:207-775-1401
Mailing Address - Street 1:1250 CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2161
Mailing Address - Country:US
Mailing Address - Phone:207-775-1401
Mailing Address - Fax:207-773-4990
Practice Address - Street 1:1250 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2161
Practice Address - Country:US
Practice Address - Phone:207-775-1401
Practice Address - Fax:207-773-4990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME24231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME114030000Medicaid