Provider Demographics
NPI:1922723543
Name:JETPORT DENTURE CENTER INC.
Entity Type:Organization
Organization Name:JETPORT DENTURE CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:AUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARBONE
Authorized Official - Suffix:
Authorized Official - Credentials:LD
Authorized Official - Phone:207-774-7645
Mailing Address - Street 1:980 FOREST AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-3357
Mailing Address - Country:US
Mailing Address - Phone:207-774-7645
Mailing Address - Fax:207-828-5298
Practice Address - Street 1:980 FOREST AVE STE 104
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-3357
Practice Address - Country:US
Practice Address - Phone:207-774-7645
Practice Address - Fax:207-828-5298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-06
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEDTR5001OtherSTATE OF MAINE DENTURIST LICENSE