Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122400000X | Denturist | 5024 | ME |
NPI | 1417287244 |
---|---|
Provider Name | Kelly Carbone |
First Address | Portland, ME 04103-3357 |
Second Address | Portland, ME 04103-3357 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/12/2009 |
Last Update Date | 21/03/2013 |