Provider Demographics
NPI:1649580853
Name:INDEPENDENT DENTURE CENTER PC
Entity Type:Organization
Organization Name:INDEPENDENT DENTURE CENTER PC
Other - Org Name:JETPORT DENTURE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CARBONE RICHARDSON
Authorized Official - Suffix:
Authorized Official - Credentials:LD
Authorized Official - Phone:207-893-1346
Mailing Address - Street 1:PO BOX 1018
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062-1018
Mailing Address - Country:US
Mailing Address - Phone:207-893-1346
Mailing Address - Fax:207-893-0114
Practice Address - Street 1:530 ROOSEVELT TRL
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:ME
Practice Address - Zip Code:04062-4901
Practice Address - Country:US
Practice Address - Phone:207-893-1346
Practice Address - Fax:207-893-0114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME5024261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME433189000Medicaid