Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | 5535 | ME |
NPI | 1467996330 |
---|---|
Provider Name | Gary Boudreau |
First Address | Benton, ME 04901-3532 |
Second Address | Bangor, ME 04401-3984 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/12/2016 |
Last Update Date | 13/12/2016 |