Provider Demographics
NPI:1598872103
Name:ORTHODONTIC ASSOCIATES PA
Entity Type:Organization
Organization Name:ORTHODONTIC ASSOCIATES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DMD ABO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:PODHOUSER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD ABO
Authorized Official - Phone:207-772-5487
Mailing Address - Street 1:440 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106
Mailing Address - Country:US
Mailing Address - Phone:207-772-5487
Mailing Address - Fax:207-772-7553
Practice Address - Street 1:440 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106
Practice Address - Country:US
Practice Address - Phone:207-772-5487
Practice Address - Fax:207-772-7553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME122300000X
NH122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty