Healthcare Provider Details

I. General information

NPI: 1366453623
Provider Name (Legal Business Name): STEPHEN BERUBE D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 BRIDGE ST
MANCHESTER NH
03101-1699
US

IV. Provider business mailing address

149 SUNSET DR
NORTHWOOD NH
03261-4901
US

V. Phone/Fax

Practice location:
  • Phone: 603-669-4111
  • Fax: 603-641-2706
Mailing address:
  • Phone: 603-669-4111
  • Fax: 603-641-2706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2590
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: