1245484310 NPI number — AMERICAN DENTAL ASSOCIATES

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 1245484310 NPI number — AMERICAN DENTAL ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AMERICAN DENTAL ASSOCIATES
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:
6
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:
1245484310
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
179 MAIN ST
Provider Second Line Business Mailing Address:
SUITE 212
Provider Business Mailing Address City Name:
WATERVILLE
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04901-6672
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-872-6815
Provider Business Mailing Address Fax Number:
207-872-6815

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
179 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 212
Provider Business Practice Location Address City Name:
WATERVILLE
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04901-6672
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-872-6815
Provider Business Practice Location Address Fax Number:
207-872-6815
Provider Enumeration Date:
11/16/2008

Additional Information

Authorized Official

Authorized Official Last Name:
AKINSANYA
Authorized Official First Name:
OLUGBENGA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
207-872-6815

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  4077 , 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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