1154446672 NPI number — COASTAL FAMILY DENTAL P.A.

Table of content: (NPI 1154446672)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154446672 NPI number — COASTAL FAMILY DENTAL P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COASTAL FAMILY DENTAL P.A.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
ALAN J. CHEBUSKE D.M.D.
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1154446672
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
110 AUBURN STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-797-7433
Provider Business Mailing Address Fax Number:
207-797-7720

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 AUBURN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-797-7433
Provider Business Practice Location Address Fax Number:
207-797-7720
Provider Enumeration Date:
03/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CHEBUSKE
Authorized Official First Name:
ALAN
Authorized Official Middle Name:
JESSE
Authorized Official Title or Position:
OWNER/BILLING ENTITY
Authorized Official Telephone Number:
207-797-7433

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  3047 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 124010000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".




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