Provider Demographics
NPI:1538541727
Name:FRYEBURG FAMILY DENTAL
Entity type:Organization
Organization Name:FRYEBURG FAMILY DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BERNADETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOZAK
Authorized Official - Suffix:
Authorized Official - Credentials:IPDH
Authorized Official - Phone:207-256-7606
Mailing Address - Street 1:PO BOX 523
Mailing Address - Street 2:19 PORTLAND STREET
Mailing Address - City:FRYEBURG
Mailing Address - State:ME
Mailing Address - Zip Code:04037-0523
Mailing Address - Country:US
Mailing Address - Phone:207-256-7606
Mailing Address - Fax:207-256-8086
Practice Address - Street 1:19 PORTLAND ST
Practice Address - Street 2:
Practice Address - City:FRYEBURG
Practice Address - State:ME
Practice Address - Zip Code:04037-1205
Practice Address - Country:US
Practice Address - Phone:207-256-7606
Practice Address - Fax:207-256-8086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEIPH18124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty