Provider Demographics
NPI:1952717084
Name:MAINE COAST ORAL SURGERY
Entity Type:Organization
Organization Name:MAINE COAST ORAL SURGERY
Other - Org Name:PORTLAND ORAL & MAXILLOFACIAL SURGERY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:J
Authorized Official - Last Name:COLLETT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:207-772-8055
Mailing Address - Street 1:1601 CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1601 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2102
Practice Address - Country:US
Practice Address - Phone:207-772-8055
Practice Address - Fax:207-772-8752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0008XDental ProvidersDentistOral and Maxillofacial RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1780995712OtherORAL & MAXILLOFACIAL SURGERY