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NPI

 123

Facility Name

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First Name

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Last Name

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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

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

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Physical Zip Code

 74,000

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

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Created at 9/26/2021 10:13 PM by ***
Last modified at 9/26/2021 10:13 PM by ***