=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518591395
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOFFSTOWN SMILES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2020
-----------------------------------------------------
Last Update Date | 03/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17A TATRO DRIVE, UNIT 102
-----------------------------------------------------
City | GOFFSTOWN
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03045-0304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-384-2038
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1984
-----------------------------------------------------
City | MERRIMACK
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03054-1984
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-257-8664
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | DR. FEREIDOUN AGHA-RAZI
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 617-257-8664
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------