Provider Demographics
NPI:1457704207
Name:GUERRA PERCOLLA, JULISSA MAGDALY (DDS)
Entity Type:Individual
Prefix:
First Name:JULISSA
Middle Name:MAGDALY
Last Name:GUERRA PERCOLLA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 FRANKLIN HEALTH CMNS
Mailing Address - Street 2:STE I
Mailing Address - City:FARMINGTON
Mailing Address - State:ME
Mailing Address - Zip Code:04938-6143
Mailing Address - Country:US
Mailing Address - Phone:207-874-1028
Mailing Address - Fax:
Practice Address - Street 1:190 PARK AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2910
Practice Address - Country:US
Practice Address - Phone:207-874-1028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1004571223G0001X
ME44881223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice