Basic Information
| Provider Information | |||||||||
| NPI: | 1134226327 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CONCORD HOSPITAL-LACONIA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | CONCORD HOSPITAL DENTAL CENTER-LACONIA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 678 | ||||||||
| Address2: | |||||||||
| City: | LACONIA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 032470678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035243211 | ||||||||
| FaxNumber: | 6035277038 | ||||||||
| Practice Location | |||||||||
| Address1: | 29 ELLIOTT ST | ||||||||
| Address2: | |||||||||
| City: | LACONIA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 032463130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035277112 | ||||||||
| FaxNumber: | 6035272835 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 05/26/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SLOANE | ||||||||
| AuthorizedOfficialFirstName: | SCOTT | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6032277000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CONCORD HOSPITAL-LACONIA | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | NH | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
ID Information
| ID | Type | State | Issuer | Description | 3071449 | 05 | NH | MEDICAID | 100 | 01 | NH | NE DELTA DENTAL | OTHER |