Healthcare Provider Details

I. General information

NPI: 1861457665
Provider Name (Legal Business Name): GRACE FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 AIRPORT RD
CONCORD NH
03301
US

IV. Provider business mailing address

143 AIRPORT RD
CONCORD NH
03301
US

V. Phone/Fax

Practice location:
  • Phone: 603-225-6650
  • Fax: 603-225-9495
Mailing address:
  • Phone: 603-225-6650
  • Fax: 603-225-9495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number3170
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2389
License Number StateNH
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number1478
License Number StateNH
# 4
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1604
License Number StateNH

VIII. Authorized Official

Name: DR. ALEX L MCCULLOCH
Title or Position: DENTIST PARTNER
Credential: DDS
Phone: 603-225-6650