1558249219 NPI number — MAINE TINY DENTAL ELIOT LLC

Table of content: (NPI 1558249219)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558249219 NPI number — MAINE TINY DENTAL ELIOT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MAINE TINY DENTAL ELIOT LLC
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:
1558249219
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
303 KIMBALL POND RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW SHARON
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04955-3703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-500-1525
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 DOW HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELIOT
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
03903-2091
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-500-3673
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/21/2025

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DESOUZA
Authorized Official First Name:
KELLI
Authorized Official Middle Name:
Authorized Official Title or Position:
IPDH/OWNER/PRESIDENT
Authorized Official Telephone Number:
207-500-1525

Provider Taxonomy Codes

  • Taxonomy code: 124Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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