Provider Demographics
NPI:1396974390
Name:CLASSIC DENTURES OF MAINE
Entity type:Organization
Organization Name:CLASSIC DENTURES OF MAINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:S
Authorized Official - Last Name:KINGSTON
Authorized Official - Suffix:
Authorized Official - Credentials:EDD ; LD
Authorized Official - Phone:207-942-1743
Mailing Address - Street 1:61 HERSEY AVE
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-4443
Mailing Address - Country:US
Mailing Address - Phone:207-942-1743
Mailing Address - Fax:
Practice Address - Street 1:61 HERSEY AVE
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-4443
Practice Address - Country:US
Practice Address - Phone:207-942-1743
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-11
Last Update Date:2009-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME5515122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME434321199Medicaid