Provider Demographics
NPI:1073018834
Name:AHERN, COLLEEN
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:AHERN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 HEMLOCK DR
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04021-4051
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4995 S COUNTY TRL
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:RI
Practice Address - Zip Code:02813-3182
Practice Address - Country:US
Practice Address - Phone:401-364-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MEDEN49351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program