Healthcare Provider Details

I. General information

NPI: 1295956944
Provider Name (Legal Business Name): CHESTNUT FAMILY DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 CHESTNUT ST
MANCHESTER NH
03104-3002
US

IV. Provider business mailing address

745 CHESTNUT ST
MANCHESTER NH
03104-3002
US

V. Phone/Fax

Practice location:
  • Phone: 603-622-7173
  • Fax: 603-668-2709
Mailing address:
  • Phone: 603-622-7173
  • Fax: 603-668-2709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number3178
License Number StateNH
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number3147
License Number StateNH

VIII. Authorized Official

Name: KAREN ANNE KENNEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 603-622-7173