Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | DTR5539 | ME |
NPI | 1801560842 |
---|---|
Provider Name | Ashley Dawn Soucy |
First Address | North Berwick, ME 03906-6519 |
Second Address | Portland, ME 04103-3357 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/08/2021 |
Last Update Date | 03/08/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
DTR5539 | STATE OF MAINE DENTAL BOARD (01) | ME |