Provider Demographics
NPI:1558249219
Name:MAINE TINY DENTAL ELIOT LLC
Entity type:Organization
Organization Name:MAINE TINY DENTAL ELIOT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:IPDH/OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:DESOUZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:207-500-1525
Mailing Address - Street 1:303 KIMBALL POND RD
Mailing Address - Street 2:
Mailing Address - City:NEW SHARON
Mailing Address - State:ME
Mailing Address - Zip Code:04955-3703
Mailing Address - Country:US
Mailing Address - Phone:207-500-1525
Mailing Address - Fax:
Practice Address - Street 1:150 DOW HWY
Practice Address - Street 2:
Practice Address - City:ELIOT
Practice Address - State:ME
Practice Address - Zip Code:03903-2091
Practice Address - Country:US
Practice Address - Phone:207-500-3673
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-08-21
Last Update Date:2025-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty