Provider Demographics
NPI:1528239910
Name:ALTA DENTAL OF MAINE, PC
Entity type:Organization
Organization Name:ALTA DENTAL OF MAINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:H
Authorized Official - Last Name:WETHERHOLD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:207-865-1900
Mailing Address - Street 1:348 US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04032-7016
Mailing Address - Country:US
Mailing Address - Phone:207-865-1900
Mailing Address - Fax:207-865-1922
Practice Address - Street 1:348 US ROUTE 1
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:ME
Practice Address - Zip Code:04032-7016
Practice Address - Country:US
Practice Address - Phone:207-865-1900
Practice Address - Fax:207-865-1922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty