Provider Demographics
NPI:1811197601
Name:DENTAL SPECIALISTS OF MAINE, LLC
Entity Type:Organization
Organization Name:DENTAL SPECIALISTS OF MAINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:JARED
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUDREAU
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, MSA
Authorized Official - Phone:207-879-0010
Mailing Address - Street 1:1355 CONGRESS ST STE A
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2137
Mailing Address - Country:US
Mailing Address - Phone:207-879-0010
Mailing Address - Fax:207-879-0011
Practice Address - Street 1:1355 CONGRESS ST STE A
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2137
Practice Address - Country:US
Practice Address - Phone:207-879-0010
Practice Address - Fax:207-879-0011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME38101223E0200X
ME40271223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty