Provider Demographics
NPI:1164596227
Name:HANOVER ROAD DENTAL HEALTH, PA
Entity Type:Organization
Organization Name:HANOVER ROAD DENTAL HEALTH, PA
Other - Org Name:KENNETH W. OLSEN, D.M.D., P.A.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:603-643-4362
Mailing Address - Street 1:367 ROUTE 120 BLDG. D
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766
Mailing Address - Country:US
Mailing Address - Phone:603-643-4362
Mailing Address - Fax:603-643-4340
Practice Address - Street 1:367 ROUTE 120 BLDG. D
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:NH
Practice Address - Zip Code:03766
Practice Address - Country:US
Practice Address - Phone:603-643-4362
Practice Address - Fax:603-643-4340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH26011223G0001X
NH14071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30314128Medicaid
NH3071380Medicaid