Provider Demographics
NPI:1649260936
Name:REIDY, LAURA ANN (DMD)
Entity type:Individual
Prefix:DR
First Name:LAURA
Middle Name:ANN
Last Name:REIDY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 PENN PLZ
Mailing Address - Street 2:SUITE 32
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-3620
Mailing Address - Country:US
Mailing Address - Phone:207-941-2300
Mailing Address - Fax:207-941-9683
Practice Address - Street 1:20 PENN PLZ
Practice Address - Street 2:SUITE 32
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3620
Practice Address - Country:US
Practice Address - Phone:207-941-2300
Practice Address - Fax:207-941-9683
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME30921223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME003734OtherBC/BS PIN NUMBER
ME1224201999Medicare ID - Type UnspecifiedPROV NUMBER