Provider Demographics
NPI:1851591630
Name:COSMETIC & GENERAL DENTISTRY OF WINTHROP
Entity Type:Organization
Organization Name:COSMETIC & GENERAL DENTISTRY OF WINTHROP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:R
Authorized Official - Last Name:WIETECHA
Authorized Official - Suffix:
Authorized Official - Credentials:FAGD
Authorized Official - Phone:207-377-6958
Mailing Address - Street 1:28 OLD WESTERN AVENUE
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:ME
Mailing Address - Zip Code:04364
Mailing Address - Country:US
Mailing Address - Phone:207-377-6958
Mailing Address - Fax:207-377-4349
Practice Address - Street 1:28 OLD WESTERN AVE
Practice Address - Street 2:
Practice Address - City:WINTHROP
Practice Address - State:ME
Practice Address - Zip Code:04364-4060
Practice Address - Country:US
Practice Address - Phone:207-377-6958
Practice Address - Fax:207-377-4349
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty