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NPI

 1,234.56

Facility Name

 Facility Name field value.

First Name

 First Name field value.

Last Name

 Last Name field value.

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

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

Physical City

 Physical City field value.

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

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

Physical Zip Code

 1,234.56

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?

 Yes

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

 Yes

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

 Yes

Dental License Number

 Dental License Number field value.
Created at 9/9/2024 2:32 PM by
Last modified at 9/9/2024 2:32 PM by