Provider Demographics
NPI:1861204513
Name:PORTLAND CENTER FOR DENTISTRY LLC
Entity type:Organization
Organization Name:PORTLAND CENTER FOR DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:732-207-1689
Mailing Address - Street 1:290 BRIDGTON RD STE 2
Mailing Address - Street 2:
Mailing Address - City:WESTBROOK
Mailing Address - State:ME
Mailing Address - Zip Code:04092-3754
Mailing Address - Country:US
Mailing Address - Phone:732-207-1689
Mailing Address - Fax:
Practice Address - Street 1:612 BRIGHTON AVE STE 1
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2359
Practice Address - Country:US
Practice Address - Phone:207-560-9057
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-21
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental