Basic Information
| Provider Information | |||||||||
| NPI: | 1225303498 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNITED CEREBRAL PALSY OF NORTHEASTERN MAINE | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 700 MOUNT HOPE AVE | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044015691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079412952 | ||||||||
| FaxNumber: | 2079412955 | ||||||||
| Practice Location | |||||||||
| Address1: | 700 MOUNT HOPE AVE | ||||||||
| Address2: | SUITE 320 | ||||||||
| City: | BANGOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 044015691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2079412952 | ||||||||
| FaxNumber: | 2079412955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/20/2012 | ||||||||
| LastUpdateDate: | 03/20/2012 | ||||||||
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| AuthorizedOfficialLastName: | OGDEN | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CAO | ||||||||
| AuthorizedOfficialTelephone: | 2079412952 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | RDH2212 | ME | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dental Hygienist |
ID Information
| ID | Type | State | Issuer | Description | 167950300 | 05 | ME | MEDICAID |