Provider Demographics
NPI:1275576829
Name:DE TOLLA, DANIEL H (DDS, MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:H
Last Name:DE TOLLA
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 GRIFFIN RD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-7145
Mailing Address - Country:US
Mailing Address - Phone:603-436-3608
Mailing Address - Fax:603-436-3646
Practice Address - Street 1:200 GRIFFIN RD
Practice Address - Street 2:SUITE 8
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-7145
Practice Address - Country:US
Practice Address - Phone:603-436-3608
Practice Address - Fax:603-436-3646
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH34721223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30303624Medicaid
NH30303624Medicaid
NHRE8323Medicare ID - Type Unspecified