Provider Demographics
NPI:1164039277
Name:BACKBAY DENTAL, LLC
Entity Type:Organization
Organization Name:BACKBAY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:CIANCARELLI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:603-569-1554
Mailing Address - Street 1:51 MILL ST
Mailing Address - Street 2:
Mailing Address - City:WOLFEBORO
Mailing Address - State:NH
Mailing Address - Zip Code:03894-4361
Mailing Address - Country:US
Mailing Address - Phone:603-569-1554
Mailing Address - Fax:
Practice Address - Street 1:51 MILL ST
Practice Address - Street 2:
Practice Address - City:WOLFEBORO
Practice Address - State:NH
Practice Address - Zip Code:03894-4361
Practice Address - Country:US
Practice Address - Phone:603-569-1554
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-23
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1134345945Medicaid