Healthcare Provider Details

I. General information

NPI: 1316151798
Provider Name (Legal Business Name): CAPITOL CENTER FOR ORAL & MAXILLOFACIAL SURGERY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 WILTON RD SUITE B
PETERBOROUGH NH
03458-1749
US

IV. Provider business mailing address

6 LOUDON RD STE 204
CONCORD NH
03301-5321
US

V. Phone/Fax

Practice location:
  • Phone: 603-784-5447
  • Fax: 603-784-5449
Mailing address:
  • Phone: 603-225-0008
  • Fax: 603-225-8120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3188
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number StateNULL

VIII. Authorized Official

Name: MICHAELA MUNIZ
Title or Position: VP, PAYOR RELATIONS
Credential:
Phone: 469-324-3242