=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538338223
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHWOOD FAMILY DENTAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2008
-----------------------------------------------------
Last Update Date | 10/17/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1505 FIRST NH TPKE
-----------------------------------------------------
City | NORTHWOOD
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03261-3217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-942-5541
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 288 1505 FIRST NH TURNPIKE
-----------------------------------------------------
City | NORTHWOOD
-----------------------------------------------------
State | NH
-----------------------------------------------------
Zip | 03261-3216
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 603-942-5541
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | FREDRICK M VEGA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 603-942-5541
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 1857
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------