Provider Demographics
NPI:1891042099
Name:GRANITE COAST ORTHODONTICS, LLC PA
Entity Type:Organization
Organization Name:GRANITE COAST ORTHODONTICS, LLC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:LALIBERTE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:207-470-7466
Mailing Address - Street 1:1056 COMMERCIAL ST
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04856-3801
Mailing Address - Country:US
Mailing Address - Phone:207-470-7466
Mailing Address - Fax:207-517-6167
Practice Address - Street 1:1056 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-3801
Practice Address - Country:US
Practice Address - Phone:207-470-7466
Practice Address - Fax:207-517-6167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN4118261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental