Healthcare Provider Details

I. General information

NPI: 1962665976
Provider Name (Legal Business Name): JASON JOSHUA PEACOCK D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 03/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 LOUDON RD #202
CONCORD NH
03301-5345
US

IV. Provider business mailing address

6 LOUDON RD #202
CONCORD NH
03301-5345
US

V. Phone/Fax

Practice location:
  • Phone: 603-228-1066
  • Fax:
Mailing address:
  • Phone: 603-228-1066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDE 00011243
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: