Healthcare Provider Details

I. General information

NPI: 1689661381
Provider Name (Legal Business Name): SREEMALI VASANTHA DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 09/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 PLEASANT ST SUITE # 3
CONCORD NH
03301-3831
US

IV. Provider business mailing address

102 PLEASANT ST SUITE # 3
CONCORD NH
03301-3831
US

V. Phone/Fax

Practice location:
  • Phone: 603-225-4143
  • Fax: 603-226-9413
Mailing address:
  • Phone: 603-225-4143
  • Fax: 603-226-9413

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3444
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: