Basic Information
| Provider Information | |||||||||
| NPI: | 1023281599 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MONADNOCK HEALTHY TEETH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 452 OLD STREET RD | ||||||||
| Address2: | |||||||||
| City: | PETERBOROUGH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 034581263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6039247191 | ||||||||
| FaxNumber: | 6039249586 | ||||||||
| Practice Location | |||||||||
| Address1: | 452 OLD STREET RD | ||||||||
| Address2: | |||||||||
| City: | PETERBOROUGH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 034581263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6039247191 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2008 | ||||||||
| LastUpdateDate: | 10/28/2009 | ||||||||
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| AuthorizedOfficialLastName: | SCHEINBLUM | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6039247191 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MONADNOCK COMMUNITY HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 30312651 | 05 | NH | MEDICAID |