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General NPI Number Information
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NPI Number | 1417292269
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Entity Type | Organization
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Legal Business Name | MERRIMACK VALLEY COSMETIC DENTISTRY, LLC
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Dates
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Enumeration Date | 12/05/2012
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Last Update Date | 03/07/2017
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Provider Practice Location Address
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Address Line | 565 TURNPIKE ST 63A
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City | NORTH ANDOVER
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State | MA
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Zip | 01845-5922
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Country | US
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Telephone | 978-683-8855
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Fax | 978-738-9687
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Provider Business Mailing Address
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Address Line | 565 TURNPIKE ST 63A
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City | NORTH ANDOVER
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State | MA
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Zip | 01845-5922
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Country | US
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Telephone | 978-683-8855
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Fax | 978-738-9687
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Authorized Official
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Title or Position | SOLE TRUSTEE
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Name | DR. DAVID NICHOLAS BARDWELL
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Credential | DMD, MS
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Telephone | 978-683-8855
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 16194
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License Number State | MA
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 16194
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License Number State | MA
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