Provider Demographics
NPI:1811994361
Name:THIVIERGE, RANDAL (DSS)
Entity type:Individual
Prefix:DR
First Name:RANDAL
Middle Name:
Last Name:THIVIERGE
Suffix:
Gender:M
Credentials:DSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 149
Mailing Address - Street 2:
Mailing Address - City:WEST ROCKPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04865-0149
Mailing Address - Country:US
Mailing Address - Phone:207-236-3100
Mailing Address - Fax:207-236-8380
Practice Address - Street 1:625 ROCKLAND ST
Practice Address - Street 2:
Practice Address - City:ROCKPORT
Practice Address - State:ME
Practice Address - Zip Code:04856-5320
Practice Address - Country:US
Practice Address - Phone:207-236-3100
Practice Address - Fax:207-236-3100
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME30371223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice