Provider Demographics
NPI:1194084731
Name:ROOSEVELT DENTAL, P.A.
Entity type:Organization
Organization Name:ROOSEVELT DENTAL, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:207-894-5580
Mailing Address - Street 1:840 ROOSEVELT TRL
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04062-5375
Mailing Address - Country:US
Mailing Address - Phone:207-894-5580
Mailing Address - Fax:207-894-5590
Practice Address - Street 1:840 ROOSEVELT TRL
Practice Address - Street 2:
Practice Address - City:WINDHAM
Practice Address - State:ME
Practice Address - Zip Code:04062-5375
Practice Address - Country:US
Practice Address - Phone:207-894-5580
Practice Address - Fax:207-894-5590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME41011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty