Basic Information
| Provider Information | |||||||||
| NPI: | 1518064047 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOUNT DESERT ISLAND HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | COMMUNITY DENTAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 WAYMAN LN | ||||||||
| Address2: | |||||||||
| City: | BAR HARBOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 046091625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072885082 | ||||||||
| FaxNumber: | 2072888620 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 COMMUNITY LANE | ||||||||
| Address2: | |||||||||
| City: | SOUTHWEST HARBOR | ||||||||
| State: | ME | ||||||||
| PostalCode: | 046794273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072442888 | ||||||||
| FaxNumber: | 2072440490 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2006 | ||||||||
| LastUpdateDate: | 10/11/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ABBOTT | ||||||||
| AuthorizedOfficialFirstName: | JENNIFER | ||||||||
| AuthorizedOfficialMiddleName: | JEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF MEDICAL STAFF SUPPORT | ||||||||
| AuthorizedOfficialTelephone: | 2072885081 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 1347980001 | ME | N | Suppliers | Durable Medical Equipment & Medical Supplies | 122300000X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 1347980001 | 01 | ME | DME SUPPLIER | OTHER |