1639385289 NPI number — ANGELA J SANTAVICCA DDS PLLC

Table of content: (NPI 1639385289)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639385289 NPI number — ANGELA J SANTAVICCA DDS PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANGELA J SANTAVICCA DDS PLLC
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:
1639385289
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
367 STATE ROUTE 120
Provider Second Line Business Mailing Address:
UNIT C
Provider Business Mailing Address City Name:
LEBANON
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03766-1430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-643-4142
Provider Business Mailing Address Fax Number:
603-643-1740

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
367 STATE ROUTE 120
Provider Second Line Business Practice Location Address:
UNIT C
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03766-1430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-643-4142
Provider Business Practice Location Address Fax Number:
603-643-1740
Provider Enumeration Date:
05/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BERGERON
Authorized Official First Name:
JODI
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
603-643-4142

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  2648 , 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: 30310640 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".




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