Provider Demographics
NPI:1962877910
Name:SOUSA, ALICIA T (RDH)
Entity type:Individual
Prefix:MISS
First Name:ALICIA
Middle Name:T
Last Name:SOUSA
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 ROSS RD
Mailing Address - Street 2:
Mailing Address - City:OLD ORCHARD BEACH
Mailing Address - State:ME
Mailing Address - Zip Code:04064-4111
Mailing Address - Country:US
Mailing Address - Phone:207-432-3188
Mailing Address - Fax:
Practice Address - Street 1:85 ROSS RD
Practice Address - Street 2:
Practice Address - City:OLD ORCHARD BEACH
Practice Address - State:ME
Practice Address - Zip Code:04064-4111
Practice Address - Country:US
Practice Address - Phone:207-432-3188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERDH3843124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist