Provider Demographics
NPI:1699421800
Name:DENTAL WELLNESS PA LLC
Entity type:Organization
Organization Name:DENTAL WELLNESS PA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:207-274-3167
Mailing Address - Street 1:105 RANGE RD
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND CENTER
Mailing Address - State:ME
Mailing Address - Zip Code:04021-3433
Mailing Address - Country:US
Mailing Address - Phone:207-274-3167
Mailing Address - Fax:
Practice Address - Street 1:295 FOREST AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2018
Practice Address - Country:US
Practice Address - Phone:207-370-0575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty