Provider Demographics
NPI:1982763801
Name:CENTRAL MAINE ORAL & MAXILLOFACIAL SURGERY ASSOCIATES, PA
Entity Type:Organization
Organization Name:CENTRAL MAINE ORAL & MAXILLOFACIAL SURGERY ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARTHA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:207-783-4705
Mailing Address - Street 1:405 CENTER STREET
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04210
Mailing Address - Country:US
Mailing Address - Phone:207-783-4705
Mailing Address - Fax:
Practice Address - Street 1:405 CENTER STREET
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210
Practice Address - Country:US
Practice Address - Phone:207-783-4705
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME30651223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM4341Medicare ID - Type Unspecified