Provider Demographics
NPI:1306337290
Name:MAINE DENTAL BOUTIQUE, LLC
Entity type:Organization
Organization Name:MAINE DENTAL BOUTIQUE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:FICHTHORN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-930-0833
Mailing Address - Street 1:16 COMMERCE PLZ STE 1A
Mailing Address - Street 2:
Mailing Address - City:WINTHROP
Mailing Address - State:ME
Mailing Address - Zip Code:04364-1562
Mailing Address - Country:US
Mailing Address - Phone:207-930-0833
Mailing Address - Fax:
Practice Address - Street 1:16 COMMERCE PLZ STE 1A
Practice Address - Street 2:
Practice Address - City:WINTHROP
Practice Address - State:ME
Practice Address - Zip Code:04364-1562
Practice Address - Country:US
Practice Address - Phone:207-930-0833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERDH4109124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty