=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063024487
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EXETER DENTAL IMPLANT AND ORAL SURGERY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2020
-----------------------------------------------------
Last Update Date | 08/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21 HAMPTON RD STE 202
-----------------------------------------------------
City | EXETER
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03833-4800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-773-3333
-----------------------------------------------------
Fax | 603-718-3096
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21 HAMPTON RD STE 202
-----------------------------------------------------
City | EXETER
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03833-4800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-773-3333
-----------------------------------------------------
Fax | 603-718-3096
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MRS. HAILEY ELIZABETH GROLEAU
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 603-527-8057
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------