Healthcare Provider Details

I. General information

NPI: 1255314951
Provider Name (Legal Business Name): ELLIOT PROFESSIONAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ELLIOT WAY ELLIOT OMS CENTER
MANCHESTER NH
03103-3502
US

IV. Provider business mailing address

1 ELLIOT WAY ELLIOT OMS CENTER
MANCHESTER NH
03103-3502
US

V. Phone/Fax

Practice location:
  • Phone: 603-625-8462
  • Fax: 603-669-2711
Mailing address:
  • Phone: 603-625-8462
  • Fax: 603-669-2711

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: RICHARD P. HERMAN
Title or Position: DIRECTOR OF OPERATIONS AND FINANCE
Credential:
Phone: 603-663-4904