Healthcare Provider Details

I. General information

NPI: 1154843464
Provider Name (Legal Business Name): JUSTIN MAILLET DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2017
Last Update Date: 09/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 HIGH ST
NASHUA NH
03060-3312
US

IV. Provider business mailing address

77 NORTHEASTERN BLVD STE C
NASHUA NH
03062-3128
US

V. Phone/Fax

Practice location:
  • Phone: 603-821-6122
  • Fax: 603-821-5620
Mailing address:
  • Phone: 603-882-3616
  • Fax: 603-595-7414

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number04328
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: