Healthcare Provider Details

I. General information

NPI: 1710535372
Provider Name (Legal Business Name): MARYSSA A ALLEN DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2019
Last Update Date: 10/25/2020
Certification Date: 10/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SHATTUCK WAY STE 5
NEWINGTON NH
03801-7876
US

IV. Provider business mailing address

104 WASHINGTON ST APT 323
DOVER NH
03820-3884
US

V. Phone/Fax

Practice location:
  • Phone: 603-436-9200
  • Fax:
Mailing address:
  • Phone: 774-254-7788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN1858457
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number04516
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: