Provider Demographics
NPI:1689494213
Name:COUNTY ROOTS CHILDRENS DENTISTRY LLC
Entity type:Organization
Organization Name:COUNTY ROOTS CHILDRENS DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIK
Authorized Official - Middle Name:ARTHUR
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:207-551-3304
Mailing Address - Street 1:P.O. BOX 4197
Mailing Address - Street 2:
Mailing Address - City:PRESQUE ISLE
Mailing Address - State:ME
Mailing Address - Zip Code:04769
Mailing Address - Country:US
Mailing Address - Phone:207-462-4767
Mailing Address - Fax:207-512-1702
Practice Address - Street 1:181 ACADEMY ST STE 4
Practice Address - Street 2:
Practice Address - City:PRESQUE ISLE
Practice Address - State:ME
Practice Address - Zip Code:04769-3178
Practice Address - Country:US
Practice Address - Phone:207-462-4767
Practice Address - Fax:207-512-1702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-10-17
Last Update Date:2024-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty