1598058968 NPI number — MANCHESTER WALK IN DENTAL CLINIC PC

Table of content: TARA THERESA GREEN RN (NPI 1891512836)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598058968 NPI number — MANCHESTER WALK IN DENTAL CLINIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MANCHESTER WALK IN DENTAL CLINIC PC
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:
1598058968
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/18/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25 S MAPLE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANCHESTER
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03103-5738
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-703-0220
Provider Business Mailing Address Fax Number:
603-703-0221

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 S MAPLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANCHESTER
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03103-5738
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-703-0220
Provider Business Practice Location Address Fax Number:
603-703-0221
Provider Enumeration Date:
05/18/2011

Additional Information

Authorized Official

Authorized Official Last Name:
MAHABA
Authorized Official First Name:
DIAA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
603-703-0220

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  03824 , 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)





Copyright © 2007-2025 www.npivalidator.com