=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093353526
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NADER MOAVENIAN, DDS PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/16/2019
-----------------------------------------------------
Last Update Date | 12/16/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5 SHEEP DAVIS RD
-----------------------------------------------------
City | PEMBROKE
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03275-3702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-224-7831
-----------------------------------------------------
Fax | 603-224-8549
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 33 TRAFALGAR SQ STE 201
-----------------------------------------------------
City | NASHUA
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03063-4901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-595-8889
-----------------------------------------------------
Fax | 603-595-2027
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BILLING COORDINATOR
-----------------------------------------------------
Name | JO GOY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 603-595-8889
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------