=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467960880
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ROBERT C. FROMUTH DDS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/19/2018
-----------------------------------------------------
Last Update Date | 01/19/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 765 S MAIN ST STE 102
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03102-5141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-644-3368
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 765 S MAIN ST STE 102
-----------------------------------------------------
City | MANCHESTER
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03102-5141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | ROBERT FROMUTH
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 603-644-3368
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 04072
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------