Healthcare Provider Details

I. General information

NPI: 1427031137
Provider Name (Legal Business Name): ROBERT F. PROVENCHER JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ELLIOT WAY 2ND FLOOR
MANCHESTER NH
03103-3502
US

IV. Provider business mailing address

1 ELLIOT WAY 2ND FLOOR
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 Number1141
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: