Provider Demographics
NPI:1154446672
Name:ALEXANDRA Y PEACOCK CATHCART DMD LLC
Entity type:Organization
Organization Name:ALEXANDRA Y PEACOCK CATHCART DMD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXANDRA
Authorized Official - Middle Name:YAMVA
Authorized Official - Last Name:PEACOCK CATHCART
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:413-446-6346
Mailing Address - Street 1:110 AUBURN STREET
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103
Mailing Address - Country:US
Mailing Address - Phone:207-797-7433
Mailing Address - Fax:207-797-7720
Practice Address - Street 1:110 AUBURN STREET
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103
Practice Address - Country:US
Practice Address - Phone:207-797-7433
Practice Address - Fax:207-797-7720
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME30471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME124010000Medicaid