Provider Demographics
NPI:1588835623
Name:NORTHWEST DENTAL
Entity Type:Organization
Organization Name:NORTHWEST DENTAL
Other - Org Name:WELLONE PRIMARY MEDICAL AND DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:BANCROFT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:401-568-7661
Mailing Address - Street 1:36 BRIDGE WAY
Mailing Address - Street 2:PO BOX 312
Mailing Address - City:PASCOAG
Mailing Address - State:RI
Mailing Address - Zip Code:02859-3131
Mailing Address - Country:US
Mailing Address - Phone:401-568-7661
Mailing Address - Fax:401-567-0900
Practice Address - Street 1:36 BRIDGE WAY
Practice Address - Street 2:
Practice Address - City:PASCOAG
Practice Address - State:RI
Practice Address - Zip Code:02859-3312
Practice Address - Country:US
Practice Address - Phone:401-568-7661
Practice Address - Fax:401-567-0900
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHWEST COMMUNITY HEALTH CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-17
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIACF01571122300000X, 261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RINW44528Medicaid