Provider Demographics
NPI:1780868687
Name:DENTAL SPECIALISTS OF PORTLAND
Entity type:Organization
Organization Name:DENTAL SPECIALISTS OF PORTLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:MARCIE
Authorized Official - Middle Name:PAULINE
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-879-0010
Mailing Address - Street 1:1355 CONGRESS ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2160
Mailing Address - Country:US
Mailing Address - Phone:207-879-0010
Mailing Address - Fax:207-879-0011
Practice Address - Street 1:1355 CONGRESS ST
Practice Address - Street 2:SUITE A
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2160
Practice Address - Country:US
Practice Address - Phone:207-879-0010
Practice Address - Fax:207-879-0011
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL SPECIALISTS OF YARMOUTH, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-27
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME38101223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty