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NPI

 123,456

Facility Name

 Domino88

First Name

 Domino88

Last Name

 Domino88

Physical Street Address -- NOTE:  Please return to complete this Survey separately for each physical service location where you provide dental services.

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Physical City

 http://52.221.213.70

Physical State (Please use state abbreviation ex: ME for Maine)

 AS

Physical Zip Code

 123,456

Are you currently accepting new MaineCare members?

 Yes

Are you able to accommodate children with special needs?

 Yes

Are you able to serve children with mobility issues such as wheelchair ramps and wider doorways?

  

Are you able to provide services to children with complex health needs such as sedation?

  

Are you able to provide services to children with intellectual disabilities such as autism?

  

Dental License Number

  
Created at 7/13/2020 6:58 AM by ***
Last modified at 7/13/2020 6:58 AM by ***