Healthcare Provider Details

I. General information

NPI: 1760693881
Provider Name (Legal Business Name): NORTHEAST ENDODONTIC SPECIALISTS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

382 DANIEL WEBSTER HWY
MERRIMACK NH
03054-1583
US

IV. Provider business mailing address

PO BOX 1583
MERRIMACK NH
03054-1583
US

V. Phone/Fax

Practice location:
  • Phone: 603-423-0400
  • Fax: 603-423-0401
Mailing address:
  • Phone: 603-423-0400
  • Fax: 603-423-0401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number3049
License Number StateNH

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. JOHN TODD JACKSON
Title or Position: PRESIDENT, OWNER
Credential: D.M.D.
Phone: 603-661-7702