Healthcare Provider Details

I. General information

NPI: 1124552104
Provider Name (Legal Business Name): HILLSIDE FAMILY DENTAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 04/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 RAYMOND ROAD
CANDIA NH
03034
US

IV. Provider business mailing address

410 RAYMOND ROAD
CANDIA NH
03034
US

V. Phone/Fax

Practice location:
  • Phone: 603-483-2176
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3965
License Number StateNH

VIII. Authorized Official

Name: DR. EMILY J PAKULA MORIARTY
Title or Position: PRESIDENT
Credential: D.M.D.
Phone: 603-483-2176