1831584929 NPI number — GREAT OUTDOORS PEDIATRIC DENTISTRY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831584929 NPI number — GREAT OUTDOORS PEDIATRIC DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT OUTDOORS PEDIATRIC DENTISTRY
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:
6
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:
1831584929
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6 OLD ROCHESTER RD
Provider Second Line Business Mailing Address:
301
Provider Business Mailing Address City Name:
DOVER
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03820-2027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-343-1228
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6 OLD ROCHESTER RD
Provider Second Line Business Practice Location Address:
301
Provider Business Practice Location Address City Name:
DOVER
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03820-2027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-343-1228
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/06/2015

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
PATRICK
Authorized Official Middle Name:
T
Authorized Official Title or Position:
OWNER, PRESIDENT
Authorized Official Telephone Number:
303-913-9951

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  04093 , 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)





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