Healthcare Provider Details

I. General information

NPI: 1588835623
Provider Name (Legal Business Name): NORTHWEST DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2008
Last Update Date: 06/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 BRIDGE WAY
PASCOAG RI
02859-3312
US

IV. Provider business mailing address

36 BRIDGE WAY PO BOX 312
PASCOAG RI
02859-3131
US

V. Phone/Fax

Practice location:
  • Phone: 401-568-7661
  • Fax: 401-567-0900
Mailing address:
  • Phone: 401-568-7661
  • Fax: 401-567-0900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberACF01571
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberACF01571
License Number StateRI

VIII. Authorized Official

Name: MR. PETER BANCROFT
Title or Position: CEO
Credential:
Phone: 401-568-7661