Provider Demographics
NPI:1922214865
Name:DENTAL ARTS OF PORTLAND
Entity Type:Organization
Organization Name:DENTAL ARTS OF PORTLAND
Other - Org Name:DENTAL ARTS BIDDEFORD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:A
Authorized Official - Last Name:MAZURENKO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:207-773-2111
Mailing Address - Street 1:2401 CONGRESS ST STE 2
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-1969
Mailing Address - Country:US
Mailing Address - Phone:207-773-2111
Mailing Address - Fax:
Practice Address - Street 1:2401 CONGRESS ST
Practice Address - Street 2:SUITE # 2
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-1932
Practice Address - Country:US
Practice Address - Phone:207-773-2111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEME3595122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty