Provider Demographics
NPI:1639110349
Name:PORTLAND DENTAL HEALTH CARE
Entity type:Organization
Organization Name:PORTLAND DENTAL HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:207-797-5000
Mailing Address - Street 1:315 AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-2179
Mailing Address - Country:US
Mailing Address - Phone:207-797-5000
Mailing Address - Fax:
Practice Address - Street 1:315 AUBURN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-2179
Practice Address - Country:US
Practice Address - Phone:207-797-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental