1144272352 NPI number — CONCORD ORAL SURGERY PROFESSIONAL ASSOCIATION

Table of content: (NPI 1144272352)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144272352 NPI number — CONCORD ORAL SURGERY PROFESSIONAL ASSOCIATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONCORD ORAL SURGERY PROFESSIONAL ASSOCIATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144272352
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
194 PLEASANT ST
Provider Second Line Business Mailing Address:
SUITE 13
Provider Business Mailing Address City Name:
CONCORD
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03301-2952
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-225-3482
Provider Business Mailing Address Fax Number:
603-224-2331

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
194 PLEASANT ST
Provider Second Line Business Practice Location Address:
SUITE 13
Provider Business Practice Location Address City Name:
CONCORD
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03301-2952
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-225-3482
Provider Business Practice Location Address Fax Number:
603-224-2331
Provider Enumeration Date:
05/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SCURA
Authorized Official First Name:
MARK
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
603-225-3482

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X , with the licence number:  2186 , registered in the state of NH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 89191315 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 129 . This is a "CIGNA" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: H000186 . This is a "CHAMPUS" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: 1053 . This is a "NORTHEAST DELTA DENTAL" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".
  • Identifier: CONC1315 . This is a "BLUE CROSS/BLUE SHIELD" identifier , issued by the state of ( NH ) . This identifiers is of the category "OTHER".




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