Provider Demographics
NPI:1770831224
Name:GORHAM FAMILY AND COSMETIC DENTISTRY PC
Entity Type:Organization
Organization Name:GORHAM FAMILY AND COSMETIC DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:W
Authorized Official - Last Name:PIDHAJECKY
Authorized Official - Suffix:
Authorized Official - Credentials:GENERAL DENTIST
Authorized Official - Phone:207-839-3006
Mailing Address - Street 1:347 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04038-1338
Mailing Address - Country:US
Mailing Address - Phone:207-839-3006
Mailing Address - Fax:207-839-4593
Practice Address - Street 1:347 MAIN ST
Practice Address - Street 2:
Practice Address - City:GORHAM
Practice Address - State:ME
Practice Address - Zip Code:04038-1338
Practice Address - Country:US
Practice Address - Phone:207-839-3006
Practice Address - Fax:207-839-4593
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-15
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY42511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1235348749OtherGENERAL DENTIST
ME1396853156OtherGENERAL DENTIST