Provider Demographics
NPI:1558966259
Name:MDG DENTAL ELLSWORTH PA LLC
Entity type:Organization
Organization Name:MDG DENTAL ELLSWORTH PA LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:GILLINS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, FACP, DABP
Authorized Official - Phone:207-374-5398
Mailing Address - Street 1:PO BOX 6158
Mailing Address - Street 2:
Mailing Address - City:BLUE HILL
Mailing Address - State:ME
Mailing Address - Zip Code:04614-6158
Mailing Address - Country:US
Mailing Address - Phone:207-374-5398
Mailing Address - Fax:
Practice Address - Street 1:292 SOUTH ST
Practice Address - Street 2:
Practice Address - City:BLUE HILL
Practice Address - State:ME
Practice Address - Zip Code:04614-6122
Practice Address - Country:US
Practice Address - Phone:207-374-5398
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-01
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1528323102Medicaid