Provider Demographics
NPI:1730817339
Name:BIGOS, ALYSSA MARION (RDH, BSDH)
Entity type:Individual
Prefix:MISS
First Name:ALYSSA
Middle Name:MARION
Last Name:BIGOS
Suffix:
Gender:F
Credentials:RDH, BSDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 W GRAND AVE APT 77
Mailing Address - Street 2:
Mailing Address - City:OLD ORCHARD BEACH
Mailing Address - State:ME
Mailing Address - Zip Code:04064-3128
Mailing Address - Country:US
Mailing Address - Phone:978-888-3885
Mailing Address - Fax:
Practice Address - Street 1:94 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2630
Practice Address - Country:US
Practice Address - Phone:207-808-9498
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-11
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERDH44351223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1992391536Medicaid