Healthcare Provider Details

I. General information

NPI: 1174564868
Provider Name (Legal Business Name): DR. ROLAND JOSEPH ST. ONGE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

363 W MAIN ST
TILTON NH
03276-5010
US

IV. Provider business mailing address

363 W MAIN ST
TILTON NH
03276-5010
US

V. Phone/Fax

Practice location:
  • Phone: 603-286-3032
  • Fax: 603-286-8445
Mailing address:
  • Phone: 603-286-3032
  • Fax: 603-286-8445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number1097
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: