=====================================================
General NPI Number Information
=====================================================
NPI Number | 1184010142
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BARBARA B MACK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2015
-----------------------------------------------------
Last Update Date | 04/07/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 252 JEWETT ST
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03103-2823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-622-7973
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 252 JEWETT ST
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03103-2823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | 00846
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------