Provider Demographics
NPI:1124352737
Name:ELLSWORTH BUCKSPORT DENTAL ASSOCIATES
Entity type:Organization
Organization Name:ELLSWORTH BUCKSPORT DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JODI
Authorized Official - Middle Name:L
Authorized Official - Last Name:SAWYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-667-7117
Mailing Address - Street 1:PO BOX 838
Mailing Address - Street 2:
Mailing Address - City:BUCKSPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04416-0838
Mailing Address - Country:US
Mailing Address - Phone:207-469-6191
Mailing Address - Fax:207-469-3816
Practice Address - Street 1:11 MECHANIC STREET
Practice Address - Street 2:
Practice Address - City:BUCKSPORT
Practice Address - State:ME
Practice Address - Zip Code:04416
Practice Address - Country:US
Practice Address - Phone:207-469-6191
Practice Address - Fax:207-469-3816
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ELLSWORTH BUCKSPORT DENTAL ASSOCIATES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-29
Last Update Date:2009-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME30361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME120010000Medicaid