1184814568 NPI number — SOUTHERN MAINE PEDIATRIC DENTISTRY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184814568 NPI number — SOUTHERN MAINE PEDIATRIC DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHERN MAINE PEDIATRIC DENTISTRY
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:
Provider Other Organization Name Type Code:
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:
1184814568
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/31/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
75 JOHN ROBERTS RD
Provider Second Line Business Mailing Address:
SUIT 10B
Provider Business Mailing Address City Name:
SOUTH PORTLAND
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04106-6914
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-773-3111
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 JOHN ROBERTS RD
Provider Second Line Business Practice Location Address:
SUIT 10B
Provider Business Practice Location Address City Name:
SOUTH PORTLAND
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04106-6914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-773-3111
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/31/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WIGNALL
Authorized Official First Name:
WHITNEY
Authorized Official Middle Name:
RALSTON
Authorized Official Title or Position:
PEDIATRIC DENTIST
Authorized Official Telephone Number:
207-773-3111

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  3767 , 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)





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