Healthcare Provider Details

I. General information

NPI: 1063624773
Provider Name (Legal Business Name): SCOTT COPELAND PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 01/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 E BROADWAY
DERRY NH
03038-1822
US

IV. Provider business mailing address

132 E BROADWAY
DERRY NH
03038-1822
US

V. Phone/Fax

Practice location:
  • Phone: 603-437-0331
  • Fax: 603-437-5096
Mailing address:
  • Phone: 603-437-0331
  • Fax: 603-437-5096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2056
License Number StateNH

VIII. Authorized Official

Name: DR. SCOTT DOUGLAS COPELAND
Title or Position: OWNER
Credential: D.D.S., M.S.
Phone: 603-437-0331