=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447702550
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MANCHESTER DENTAL ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2016
-----------------------------------------------------
Last Update Date | 10/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6 ROCKWOOD DR
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04351-3353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-382-7819
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 SILVER DR
-----------------------------------------------------
City | YARMOUTH
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04096-7759
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-847-0414
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. ROHINI BADLANI
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 786-382-7819
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DEN4318
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------