Healthcare Provider Details

I. General information

NPI: 1376094821
Provider Name (Legal Business Name): BADRI ISMAEEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2016
Last Update Date: 10/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 FRESH RIVER RD
EPPING NH
03042-2222
US

IV. Provider business mailing address

17 FRESH RIVER RD
EPPING NH
03042-2222
US

V. Phone/Fax

Practice location:
  • Phone: 603-734-5366
  • Fax:
Mailing address:
  • Phone: 603-734-5366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number04264
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: