Provider Demographics
NPI:1013121193
Name:KENNEBUNK FAMILY DENTAL CARE
Entity Type:Organization
Organization Name:KENNEBUNK FAMILY DENTAL CARE
Other - Org Name:KENNEBUNK CENTER FOR DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:207-985-7944
Mailing Address - Street 1:2 LIVEWELL DRIVE
Mailing Address - Street 2:SUITE #105
Mailing Address - City:KENNEBUNK
Mailing Address - State:ME
Mailing Address - Zip Code:04043
Mailing Address - Country:US
Mailing Address - Phone:207-985-7944
Mailing Address - Fax:207-985-8718
Practice Address - Street 1:2 LIVEWELL DRIVE
Practice Address - Street 2:SUITE #105
Practice Address - City:KENNEBUNK
Practice Address - State:ME
Practice Address - Zip Code:04043
Practice Address - Country:US
Practice Address - Phone:207-985-7944
Practice Address - Fax:207-985-8717
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENNEBUNK FAMILY DENTAL CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-09
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME1223G0001X
ME31561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME132160000Medicaid