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General NPI Number Information
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NPI Number | 1831584929
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Entity Type | Organization
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Legal Business Name | GREAT OUTDOORS PEDIATRIC DENTISTRY
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Dates
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Enumeration Date | 04/06/2015
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Last Update Date | 04/06/2015
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Provider Practice Location Address
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Address Line | 6 OLD ROCHESTER RD 301
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City | DOVER
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State | NH
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Zip | 03820-2027
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Country | US
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Telephone | 603-343-1228
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Fax |
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Provider Business Mailing Address
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Address Line | 6 OLD ROCHESTER RD 301
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City | DOVER
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State | NH
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Zip | 03820-2027
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Country | US
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Telephone | 603-343-1228
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Fax |
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Authorized Official
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Title or Position | OWNER, PRESIDENT
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Name | DR. PATRICK T WILSON
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Credential | DMD
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Telephone | 303-913-9951
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 04093
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License Number State | NH
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