Provider Demographics
NPI:1063682334
Name:NORTHEAST FAMILY DENTAL CENTER PC
Entity Type:Organization
Organization Name:NORTHEAST FAMILY DENTAL CENTER PC
Other - Org Name:NE DENTAL VISIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:BOULARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-882-6055
Mailing Address - Street 1:193 KINSLEY ST
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03060-3658
Mailing Address - Country:US
Mailing Address - Phone:603-882-6055
Mailing Address - Fax:
Practice Address - Street 1:193 KINSLEY ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-3658
Practice Address - Country:US
Practice Address - Phone:603-882-6055
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-03
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2605122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty