Provider Demographics
NPI:1356216949
Name:JET DENTAL OF MAINE, PLLC
Entity type:Organization
Organization Name:JET DENTAL OF MAINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:POWELL-WASSERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-220-3714
Mailing Address - Street 1:443 WESTERN AVE # 1024
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-1726
Mailing Address - Country:US
Mailing Address - Phone:801-430-9262
Mailing Address - Fax:
Practice Address - Street 1:443 WESTERN AVE # 1024
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-1726
Practice Address - Country:US
Practice Address - Phone:801-430-9262
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JET MANAGEMENT SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2025-10-06
Last Update Date:2025-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty