Provider Demographics
NPI:1669502795
Name:THERIAULT, DONALD LEON (DMD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:LEON
Last Name:THERIAULT
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:595 BRIGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2322
Mailing Address - Country:US
Mailing Address - Phone:207-774-1471
Mailing Address - Fax:
Practice Address - Street 1:595 BRIGHTON AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2322
Practice Address - Country:US
Practice Address - Phone:207-774-1471
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME29741223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics