Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223G0001X | General Practice | DS039922 | PA |
N | 213EG0000X | General Practice | DS039922 | PA |
Y | 1223P0106X | Oral and Maxillofacial Pathology | DEN4593 | ME |
NPI | 1881094068 |
---|---|
Provider Name | Dr. Tessie Buraczewski Stansbury |
First Address | South Portland, ME 04106-3266 |
Second Address | Portland, ME 04103 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/08/2014 |
Last Update Date | 13/10/2018 |