| Full Name | |
|---|---|
| Speciality | Dentist - Periodontics |
| Location | 276 Canco Rd, Portland, Maine |
| Authorized Official Name and Position | Denise M Theriault (OWNER) |
| Authorized Official Contact | 2077801922 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
276 Canco Rd Portland ME 04103 Ph: (207) 780-1822 | 276 Canco Rd Portland ME 04103 Ph: (207) 780-1822 |
| NPI Number | 1295828069 |
|---|---|
| Provider Enumeration Date | 10/02/2006 |
| Last Update Date | 08/22/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1295828069 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223P0300X | Dentist - Periodontics | 3390 (Maine) | Primary |
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