Provider Demographics
NPI:1215505680
Name:TWIN PINES EXTRACTION AND DENTURE CENTER
Entity type:Organization
Organization Name:TWIN PINES EXTRACTION AND DENTURE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:R
Authorized Official - Last Name:LIVINGSTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:207-659-8620
Mailing Address - Street 1:PO BOX 45
Mailing Address - Street 2:
Mailing Address - City:ORONO
Mailing Address - State:ME
Mailing Address - Zip Code:04473-0045
Mailing Address - Country:US
Mailing Address - Phone:207-659-8620
Mailing Address - Fax:207-262-0424
Practice Address - Street 1:12 STILLWATER AVE STE 6
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-3984
Practice Address - Country:US
Practice Address - Phone:207-992-2060
Practice Address - Fax:207-262-0424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1184154486Medicaid