Provider Demographics
NPI:1467835678
Name:MAINELY KIDS & TEENS, LLC
Entity type:Organization
Organization Name:MAINELY KIDS & TEENS, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCUS
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:WILKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:207-951-0225
Mailing Address - Street 1:ONE CUMBERLAND PL
Mailing Address - Street 2:STE 116
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5083
Mailing Address - Country:US
Mailing Address - Phone:207-974-3018
Mailing Address - Fax:
Practice Address - Street 1:ONE CUMBERLAND PL
Practice Address - Street 2:STE 116
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5083
Practice Address - Country:US
Practice Address - Phone:207-974-3018
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-07
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDEN44481223P0221X
MEDEN42561223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty