Provider Demographics
NPI:1457360562
Name:BANGOR FAMILY DENTISTRY
Entity Type:Organization
Organization Name:BANGOR FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:L
Authorized Official - Last Name:CARREIRA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, DDS
Authorized Official - Phone:207-947-4767
Mailing Address - Street 1:83 RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-2652
Mailing Address - Country:US
Mailing Address - Phone:207-947-4767
Mailing Address - Fax:207-947-7112
Practice Address - Street 1:83 RIDGEWOOD DR
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-2652
Practice Address - Country:US
Practice Address - Phone:207-947-4767
Practice Address - Fax:207-947-7112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME20981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME104880000Medicaid
ME828257OtherUNITED CONCORDIA