Provider Demographics
NPI:1326216680
Name:NORTHEASTERN PEDIATRIC DENTAL
Entity Type:Organization
Organization Name:NORTHEASTERN PEDIATRIC DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DMD OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MINA
Authorized Official - Middle Name:H
Authorized Official - Last Name:KALALI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:603-880-5002
Mailing Address - Street 1:78 NORTHEASTERN BLVD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03062
Mailing Address - Country:US
Mailing Address - Phone:603-880-5002
Mailing Address - Fax:603-880-1877
Practice Address - Street 1:78 NORTHEASTERN BLVD
Practice Address - Street 2:SUITE 6
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03062
Practice Address - Country:US
Practice Address - Phone:603-880-5002
Practice Address - Fax:603-880-1877
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHEASTERN PEDIATRIC DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-20
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH33741223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30303168Medicaid