Provider Demographics
NPI:1528130283
Name:42 NORTH DENTAL CARE, PLLC
Entity type:Organization
Organization Name:42 NORTH DENTAL CARE, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF CLINICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANGELO
Authorized Official - Last Name:SCIALABBA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:781-647-0772
Mailing Address - Street 1:650 BRIGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-1035
Mailing Address - Country:US
Mailing Address - Phone:207-773-6331
Mailing Address - Fax:
Practice Address - Street 1:650 BRIGHTON AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-1035
Practice Address - Country:US
Practice Address - Phone:207-773-6331
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME2954122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME329670099Medicaid
ME251480099Medicaid
ME315660099Medicaid