Provider Demographics
NPI:1154843464
Name:MAILLET, JUSTIN (DMD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:MAILLET
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 NORTHEASTERN BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03062-3128
Mailing Address - Country:US
Mailing Address - Phone:603-882-3616
Mailing Address - Fax:603-595-7414
Practice Address - Street 1:45 HIGH ST
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-3312
Practice Address - Country:US
Practice Address - Phone:603-821-6122
Practice Address - Fax:603-821-5620
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-10
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH04328122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist