Provider Demographics
NPI:1811575202
Name:BREAKWATER DENTAL, LLC
Entity type:Organization
Organization Name:BREAKWATER DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SHILO
Authorized Official - Middle Name:
Authorized Official - Last Name:ANNIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:207-272-9847
Mailing Address - Street 1:5 MIDNIGHT LN
Mailing Address - Street 2:
Mailing Address - City:GORHAM
Mailing Address - State:ME
Mailing Address - Zip Code:04038-2376
Mailing Address - Country:US
Mailing Address - Phone:207-272-9847
Mailing Address - Fax:
Practice Address - Street 1:25 LONG CREEK DR UNIT D
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-2440
Practice Address - Country:US
Practice Address - Phone:207-775-2072
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-29
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty