Basic Information
Provider Information | |||||||||
NPI: | 1417407388 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ALICE PECK DAY MEMORIAL HOSPITAL | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | UPPER VALLEY SMILES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 10 ALICE PECK DAY DR | ||||||||
Address2: |   | ||||||||
City: | LEBANON | ||||||||
State: | NH | ||||||||
PostalCode: | 037662900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6034483121 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 10 ALICE PECK DAY DR | ||||||||
Address2: |   | ||||||||
City: | LEBANON | ||||||||
State: | NH | ||||||||
PostalCode: | 037662900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6034439548 | ||||||||
FaxNumber: | 6034425144 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/04/2016 | ||||||||
LastUpdateDate: | 10/04/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MOONEY | ||||||||
AuthorizedOfficialFirstName: | SUSAN | ||||||||
AuthorizedOfficialMiddleName: | E | ||||||||
AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6034425672 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | ALICE PECK DAY MEMORIAL HOSPITAL | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D., M.S. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223D0001X | 1021-V | NH | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Dental Public Health |
No ID Information.