Provider Demographics
NPI:1619168655
Name:FALMOUTH PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:FALMOUTH PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:207-781-2272
Mailing Address - Street 1:6 FUNDY RD
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04105-1705
Mailing Address - Country:US
Mailing Address - Phone:207-781-2272
Mailing Address - Fax:207-781-3605
Practice Address - Street 1:6 FUNDY RD
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04105-1705
Practice Address - Country:US
Practice Address - Phone:207-781-2272
Practice Address - Fax:207-781-3605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
23121223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty