Provider Demographics
NPI:1295814580
Name:WENTWORTH-DOUGLASS COMMUNITY DENTAL CENTER
Entity Type:Organization
Organization Name:WENTWORTH-DOUGLASS COMMUNITY DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR REVENUE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:GAGNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:603-749-3013
Mailing Address - Street 1:668 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:NH
Mailing Address - Zip Code:03820-3414
Mailing Address - Country:US
Mailing Address - Phone:603-749-3013
Mailing Address - Fax:603-749-2915
Practice Address - Street 1:668 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:NH
Practice Address - Zip Code:03820
Practice Address - Country:US
Practice Address - Phone:603-749-3013
Practice Address - Fax:603-749-2915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3081310Medicaid
ME432003800Medicaid