Provider Demographics
NPI:1790715142
Name:BERUBE, R. ROBERT (DDS)
Entity Type:Individual
Prefix:
First Name:R.
Middle Name:ROBERT
Last Name:BERUBE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:FACIAL & ORAL SURGERY ASSOCIATES, PA
Mailing Address - Street 2:5 COMMUNITY DRIVE
Mailing Address - City:AUGUSTA
Mailing Address - State:ME
Mailing Address - Zip Code:04330
Mailing Address - Country:US
Mailing Address - Phone:207-622-5814
Mailing Address - Fax:207-621-4360
Practice Address - Street 1:FACIAL & ORAL SURGERY ASSOCIATES, PA
Practice Address - Street 2:5 COMMUNITY DRIVE
Practice Address - City:AUGUSTA
Practice Address - State:ME
Practice Address - Zip Code:04330
Practice Address - Country:US
Practice Address - Phone:207-622-5814
Practice Address - Fax:207-621-4360
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME34231223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME010418322Medicaid
BB3148550OtherDEA
MEMM4723Medicare PIN
ME010418322Medicaid