Provider Demographics
NPI:1316955396
Name:ACADEMY DENTAL PA
Entity type:Organization
Organization Name:ACADEMY DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE/BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SANDI
Authorized Official - Middle Name:
Authorized Official - Last Name:BOUCHARD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:207-764-3764
Mailing Address - Street 1:179 ACEDEMY ST
Mailing Address - Street 2:
Mailing Address - City:PRESQUE ISLE
Mailing Address - State:ME
Mailing Address - Zip Code:04769
Mailing Address - Country:US
Mailing Address - Phone:207-764-3764
Mailing Address - Fax:207-764-3367
Practice Address - Street 1:179 ACEDEMY ST
Practice Address - Street 2:
Practice Address - City:PRESQUE ISLE
Practice Address - State:ME
Practice Address - Zip Code:04769
Practice Address - Country:US
Practice Address - Phone:207-764-3764
Practice Address - Fax:207-764-3367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME129220000Medicaid