Healthcare Provider Details

I. General information

NPI: 1609123140
Provider Name (Legal Business Name): BAYSIDE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2012
Last Update Date: 08/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

291 MAIN ST.
ALTON NH
03809
US

IV. Provider business mailing address

PO BOX 670
ALTON NH
03809-0670
US

V. Phone/Fax

Practice location:
  • Phone: 603-855-2017
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number03588
License Number StateNH

VIII. Authorized Official

Name: VIENA POSADA
Title or Position: DENTIST
Credential:
Phone: 603-855-2017