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General NPI Number Information
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NPI Number | 1205852340
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Entity Type | Organization
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Legal Business Name | BEDFORD COMMONS PERIODONTICS PA
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Dates
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Enumeration Date | 07/14/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 303 RIVERWAY PL
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City | BEDFORD
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State | NH
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Zip | 03110-6744
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Country | US
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Telephone | 603-623-6639
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Fax | 603-644-5398
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Provider Business Mailing Address
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Address Line | 303 RIVERWAY PL
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City | BEDFORD
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State | NH
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Zip | 03110-6744
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Country | US
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Telephone | 603-623-6639
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Fax | 603-644-5398
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Authorized Official
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Title or Position | PERIODONTIST
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Name | CHARLES DOUGLAS NEAL
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Credential | DMD
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Telephone | 603-623-6639
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 1308
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License Number State | NH
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