Organization
INDEPENDENT DENTURE CENTER PC
Active
Other names
Jetport Denture Center
Organization subpart
No
Provider details
NPI number
Authorized official
MS. KELLY CARBONE RICHARDSON LD (PRESIDENT)
(207) 893-1346
Entity
Organization
Contact information
Practice address
530 ROOSEVELT TRL, WINDHAM, ME 04062-4901
(207) 893-1346
(207) 893-0114
Mailing address
PO BOX 1018, WINDHAM, ME 04062-1018
(207) 893-1346
(207) 893-0114
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
5024
ME
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
433189000
—
ME
Enumeration date
10/21/2010
Last updated
10/21/2010
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