Healthcare Provider Details

I. General information

NPI: 1922054584
Provider Name (Legal Business Name): ELLIS LAWRENCE ROLETT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR DARTMOUTH-HITCHCOCK CLINIC
LEBANON NH
03756-1000
US

IV. Provider business mailing address

4 BALCH HILL LN
HANOVER NH
03755-1622
US

V. Phone/Fax

Practice location:
  • Phone: 603-650-5700
  • Fax: 603-650-6164
Mailing address:
  • Phone: 603-650-1360
  • Fax: 603-650-1360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number5751
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: