Basic Information
| Provider Information | |||||||||
| NPI: | 1568477982 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARIETTA | ||||||||
| FirstName: | CHANDLER | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 85 SPRING ST | ||||||||
| Address2: | |||||||||
| City: | LACONIA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 032463113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035247402 | ||||||||
| FaxNumber: | 6035240945 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 SPRING STREET | ||||||||
| Address2: | ENT ASSOCIATES OF NEW HAMPSHIRE | ||||||||
| City: | LACONIA | ||||||||
| State: | NH | ||||||||
| PostalCode: | 032463113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6035247402 | ||||||||
| FaxNumber: | 6035240945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 08/31/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | T0557 | NH | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 104228 | MN | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 15543 | NH | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 15543 | 01 | NH | LICENSE | OTHER | 3077638 | 05 | NH | MEDICAID |