Provider Demographics
NPI:1669607644
Name:MAINE DENTAL HEALTH OUT-REACH, INC
Entity type:Organization
Organization Name:MAINE DENTAL HEALTH OUT-REACH, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSANNE
Authorized Official - Middle Name:J
Authorized Official - Last Name:LAVALLEE
Authorized Official - Suffix:
Authorized Official - Credentials:RDH
Authorized Official - Phone:207-377-7003
Mailing Address - Street 1:PO BOX 275
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:ME
Mailing Address - Zip Code:04364-0275
Mailing Address - Country:US
Mailing Address - Phone:207-377-7003
Mailing Address - Fax:
Practice Address - Street 1:45 GREENWOOD TER
Practice Address - Street 2:
Practice Address - City:WINTHROP
Practice Address - State:ME
Practice Address - Zip Code:04364-1505
Practice Address - Country:US
Practice Address - Phone:207-377-7003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-20
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME431944500Medicaid