Provider Demographics
NPI:1801560842
Name:SOUCY, ASHLEY DAWN (LD)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:DAWN
Last Name:SOUCY
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:DAWN
Other - Last Name:LIBBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:57 NOWELL ST
Mailing Address - Street 2:
Mailing Address - City:NORTH BERWICK
Mailing Address - State:ME
Mailing Address - Zip Code:03906-6519
Mailing Address - Country:US
Mailing Address - Phone:207-794-5322
Mailing Address - Fax:
Practice Address - Street 1:980 FOREST AVE STE 104
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-3357
Practice Address - Country:US
Practice Address - Phone:207-774-7645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDTR5539122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEDTR5539OtherSTATE OF MAINE DENTAL BOARD