Healthcare Provider Details

I. General information

NPI: 1063024487
Provider Name (Legal Business Name): EXETER DENTAL IMPLANT AND ORAL SURGERY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

21 HAMPTON RD STE 202
EXETER NH
03833-4800
US

IV. Provider business mailing address

21 HAMPTON RD STE 202
EXETER NH
03833-4800
US

V. Phone/Fax

Practice location:
  • Phone: 603-773-3333
  • Fax: 603-718-3096
Mailing address:
  • Phone: 603-773-3333
  • Fax: 603-718-3096

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MRS. HAILEY ELIZABETH GROLEAU
Title or Position: MANAGER
Credential:
Phone: 603-527-8057