Provider Demographics
NPI:1386061422
Name:ABBOTT, PAMELA (IPH)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:IPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 STATE ST
Mailing Address - Street 2:SUITE 24
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5435
Mailing Address - Country:US
Mailing Address - Phone:207-852-3022
Mailing Address - Fax:207-852-3022
Practice Address - Street 1:263 STATE ST
Practice Address - Street 2:SUITE 24
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5435
Practice Address - Country:US
Practice Address - Phone:207-852-3022
Practice Address - Fax:207-852-3022
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-26
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEIPH70124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME464647669Medicaid